[Actions of the French Military Medical Service in the war against COVID-19: mari transve mare, hominibus semper prodesse !] / 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 !

"We are at war!" declared President Emmanuel Macron during a speech to the nation on March 16, 2020. As part of this national resilience, the French Military Medical Service was engaged in the fight against COVID-19. This general review aims to describe and detail the actions undertaken by the French Military Medical Service in the national fight against the COVID-19 pandemic in France, as well as abroad. Experts in each field reported on the major actions taken by the French Military Medical Service during the COVID-19 pandemic in France, both domestically and overseas, beginning in spring 2020. In just a few weeks, the French Military Medical Service developed ad hoc medical capabilities to support the national health authorities. It has also implemented collective medical evacuation capabilities by air and sea. A military field hospital dedicated to intensive care was also deployed to support the civilian hospital in Mulhouse. Later, military intensive care modules helped hospitals overwhelmed by the influx of COVID-19 patients in Guadeloupe, Martinique, Guyana, Mayotte and New Caledonia. A COVID-19 crisis unit coordinated the actions of the French armed forces in the fight against the pandemic. The French military center for epidemiology and public health provided all the necessary information to guide the public health and medical decision-making processes. Army medical centers organized primary care for military patients, with extensive use of telemedicine. The emergency medical services of the Paris Fire Brigade and the Marseille Marine Fire Battalion provided pre-hospital care for patients with COVID-19. The eight French military training hospitals cooperated with the civilian regional health agencies to provide hospital care for the most severe patients, but also to create de novo vaccination centers. The military medical supply chain has supported all deployments of operational medical units in France and abroad, facing a growing shortage of medical equipment. The Armed forces Biomedical Research Institute performed diagnostics, engaged in multiple research projects, updated the scientific literature review on COVID-19 daily, and provided expert recommendations on biosecurity. Finally, students from the Lyon-Bron military health schools volunteered to participate in the fight against the COVID-19 pandemic. In conclusion, in an unprecedented medical crisis, the French military medical service engaged in multiple innovative and adaptive actions, which are still ongoing, in the fight against COVID-19. Collaboration between military and civilian health systems has reinforced the common goal of "saving the most.".

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'.

Tactical damage control resuscitation in austere military environments.

BACKGROUND: Despite the early uses of tourniquets and haemostatic dressings, blood loss still accounts for the vast majority of preventable deaths on the battlefield. Over the last few years, progress has been made in the management of such injuries, especially with the use of damage control resuscitation concepts. The early application of these procedures, on the field, may constitute the best opportunity to improve survival from combat injury during remote operations. DATA SOURCES: Currently available literature relating to trauma-induced coagulopathy treatment and far-forward transfusion was identified by searches of electronic databases. The level of evidence and methodology of the research were reviewed for each article. The appropriateness for field utilisation of each medication was then discussed to take into account the characteristics of remote military operations. CONCLUSIONS: In tactical situations, in association with haemostatic procedures (tourniquet, suture, etc), tranexamic acid should be the first medication used according to the current guidelines. The use of fibrinogen concentrate should also be considered for patients in haemorrhagic shock, especially if point-of-care (POC) testing of haemostasis or shock severity is available. If POC evaluation is not available, it seems reasonable to still administer this treatment after clinical assessment, particularly if the evacuation is delayed. In this situation, lyophilised plasma may also be given as a resuscitation fluid while respecting permissive hypotension. Whole blood transfusion in the field deserves special attention. In addition to the aforementioned treatments, if the field care is prolonged, whole blood transfusion must be considered if it does not delay the evacuation.

[Contribution of information technologies to assess and improve professional practice: example of management of surgical antibiotic prophylaxis]. / Apport de l'outil informatique dans l'application de protocoles : exemple de l'antibioprophylaxie chirurgicale.

INTRODUCTION: Information technologies appear to be interesting tools to assess and improve professional practices. In that setting, the management of surgical antibiotic prophylaxis represents an appropriate clinical area for using and evaluating such a tool. Despite the existence of guidelines in one hand and the demonstrated interest for a strict application of recommendations in the other hand, some irregularities in the management of surgical antibiotic prophylaxis remain in France in 2010. OBJECTIVES: Since we have had computer systems in our department for several years, we performed an evaluation of practice to assess the impact of both the computer-based help and the updating of knowledge in physicians as tools to improve the application of guidelines for surgical antibiotic prophylaxis. STUDY DESIGN: Clinical audits. METHODS: Three clinical audits have therefore been performed before an implementation of computer-based help for clinical decisions and a clinical update for physicians, immediately after, and two years after this combined procedure (2322, 2678 and 2863 patients, respectively). RESULTS: There was an enhancement of clinical practices and compliance to guidelines secondary to the beginning of computer-based prescription (55 to 81%, P<0.05). However, a weaning effect was observed with longer intervals between clinical update and surgical procedure, in association with increased omissions of antibiotic prophylaxis. CONCLUSION: Computer-based help for clinical decision and prescription seems to be a useful tool for surgical antibiotic prophylaxis but it should be accompanied by direct regular educational measures to update protocols and databases.

[Cricothyrotomy for airways management: current data and interest for combat casualty care]. / La cricothyrotomie : données actuelles et intérêt de cette technique en médecine de guerre.

OBJECTIVES: To detail current data in cricothyrotomy and imperatives of airway management in combat casualty care. METHODS: Review of the literature in Medline database over the past 40 years. RESULTS: Modern armed conflicts, including guerrilla and terrorism, have changed the approach of tactical combat casualty care. The first medical support must be as close as possible to the battlefield, reducing casualties thanks to a quick intervention. Because of a lack of physicians on the battlefield, the first operator is often a paramedical staff trained to simple lifesaving procedures. The orotracheal intubation remains the gold standard for airways management, but often impossible because of the environmental factors of the battlefield. Therefore, cricothyrotomy may become an interesting choice in this case and not only an alternative for orotracheal intubation like in civilian practice. It provides an easy and safe underglottis airways access by a laryngotomy between the cricoid and the thyroid cartilages. Performed by paramedical staff, it is a strictly protocolized delegated medical prescription. CONCLUSION: This review of literature and the analysis of commercial kits prompt us to suggest safe methods that can be performed on battlefield. Surgical methods and MiniTrach II kit (Portex) seem to be particularly suitable for battlefield situations. An airways management algorithm for combat casualty care is also proposed.

[Acute renal failure related to urinary retention following haemorrhoidectomy performed under general anaesthesia and bilateral pudendal nerve block: a case report]. / Insuffisance rénale obstructive dans les suites d'une chirurgie hémorroïdaire réalisée sous anesthésie générale et bloc pudendal bilatéral: à propos d'un cas.

Anorectal surgery is associated with significant postoperative pain. Pudendal nerve blocks, formerly performed by surgeons, provides effective postoperative analgesia and allow a quicker recovery, which is quite important in the current concept of fast-track postoperative care. However, even for benign surgery with a safe anaesthetic technique, serious adverse events may occur. We report a case of acute renal failure related to urinary retention. Hidden by a prior history of urination difficulties, recognition of symptoms, following haemorrhoidectomy performed with bilateral pudendal block, was late. After complete recovery, electrophysiologic investigations found hypotonic, hypocontractile bladder.Therefore, before performing haemorrhoidectomy with regional anaesthesia, prior history of urination difficulties should be searched. The risk of urinary retention due to surgery and anaesthesia may be increased, as observed in this original case report.

Beat-by-beat cardiovascular index to predict unexpected intraoperative movement in anesthetized unparalyzed patients: a retrospective analysis.

OBJECTIVE: Unexpected intraoperative movement may be detrimental during delicate surgery. This study tested retrospectively an algorithm based on beat-by-beat circulatory variables (incorporated into a Cardiovascular depth of anesthesia index: CARDEAN in relationship to unexpected movement, and compared its performance to that of the electroencephalogram (EEG)-derived index: BIS-XP 4.0. METHODS: 40 ASA I or II patients presenting for knee surgery had EEG (BIS XP 4.0), beat-by-beat (Finapres) finger non-invasive blood pressure (BP), conventional brachial BP and electrocardiogram (EKG) monitors attached. Anesthesia was induced and maintained with propofol and remifentanil. Before incision, the propofol concentration was set to maintain BIS < 60. From incision to emergence, the anesthesiologist was denied access to BIS or Finapres. Anesthesia adjustment was titrated at the discretion of the anesthesiologist according to conventional signs only: brachial BP, EKG, eyelash reflex, movement. Occurrences of movement and eye signs (divergence of eyeballs, tears, corneal reflex, eyelash reflex) were observed. The CARDEAN algorithm was written retrospectively and tested vs. BIS. RESULTS: 11 movements occurred in 8 patients. CARDEAN > 60 predicted movement in 30% of the cases, 15 to 274 s before movement (sensitivity: 100%, specificity: 95%; relative operating curve ROC = 0.98; prediction probability pk = 0.98). BIS > 60 predicted movement in 19% of cases (sensitivity: 64%; specificity: 94%, ROC: 0.85, pk: 0.85). CONCLUSION: Retrospectively, a cardiovascular index predicted unexpected intraoperative movements. Prospective validation is needed.

Screening for multidrug-resistant bacteria as a predictive test for subsequent onset of nosocomial infection.

OBJECTIVE: To investigate whether carriage of multidrug-resistant bacteria is a risk factor for nosocomial infection and whether detection of carriage is predictive of subsequent onset of nosocomial infection. METHODS: In this observational cohort (study period, June 1998 through October 2002), nasal and rectal swab specimens from 412 consecutive patients admitted to the intensive care unit were tested for carriage of multidrug-resistant bacteria. Concomitantly, the bacteria responsible for any subsequent nosocomial infection, the date of infection, and some of the known clinical risk factors for nosocomial infection were noted. These factors were adjusted for potential confounders, using a Cox model stratified on the propensity score of multidrug-resistant bacteria carriage. The diagnostic characteristics of a carriage test, including the positive and negative diagnostic likelihood ratios, were calculated for all strata of the propensity score. RESULTS: Forty-two patients were carrying multidrug-resistant bacteria. Nosocomial infection occurred in 95 patients, of whom 16 (38%) were carriers, and 79 (83%) were noncarriers (P=.01). After adjustment for potential confounders, statistical analysis revealed that carriage remained a risk factor for nosocomial infection (relative risk, 2.08 [95% confidence interval {CI}, 1.13-3.81]). Receipt of antibiotic treatment at the time of intensive care unit admission was found to be protective against nosocomial infection. A positive result of test for detection of carriage seemed to be an efficient predictor of subsequent nosocomial infection (positive diagnostic likelihood ratio, 2.05 [95% CI, 1.15-3.66]), although a negative test result was not a predictor of subsequent nosocomial infection (negative likelihood ratio, 0.91 [95% CI, 0.73-1.11]). CONCLUSION: Carriage proved to be a risk factor for subsequent nosocomial infection. However, the carriage test was useful as a predictive tool only for patients with a positive test result.

[Important hypercalcaemia due to hyperparathyroidism induced by lithium]. / Hypercalcémie grave secondaire à une hyperparathyroïdie induite par le lithium.

Lithium treatment, which is still extensively used in bipolar affective disorders, may give rise to hypercalcaemia induced by hyperparathyroidism. We present a patient of 50-year-old treated with lithium for 19 years for bipolar illness and who developed an important hypercalcaemia. After symptomatic treatment of the hypercalcaemia and extrarenal dialysis the clinical evolution was favorable but measurements of serum calcium and parathormon showed that he had developed hyperparathyroidism. Neck exploration was performed and parathyroid adenomas, which had been detected by scintigraphy was removed. The lithium treatment expose to many side effects. Among other biologically and clinically important effects of lithium the possible induction of hyperparathyroidism was first suggested in 1973. Since, 1973, since about forty case reports have been described. Few cross-sectional studies show a relationship of lithium to hyperparathyroidism. Unusual metabolic features are associated with hyperparathyroidism and long-term lithium treatment: low urinary calcium excretion, normal urinary cyclic AMP excretion. The mechanism probably results from lithium linking with the calcium receptor on the parathyroid and then stimulating PTH secretion. The cessation of lithium therapy does not lead to normocalocaemia and a parathyroidectomy is usually indicated.

[Hypokalaemic paralysis disclosing hyperthyroidism]. / Paralysie hypokaliémique révélant une hyperthyroïdie.

Thyrotoxic hypokaliaemic paralysis is a rare cause of severe hypokalaemia. We report the case of a 34-year-old Asiatic man who presented in our emergency department an episode of quadriplegia due to low plasma potassium levels. Biological test discovered a Basedow disease, confirmed thyrotoxic paralysis. Intravenously potassium treatment allowed complete recovery from paralysis. Also, the patient received specific medical treatment with antithyroid drugs and propranolol.

[Convulsions due to a postpartum cerebral angiopathy associated with the administration of bromocriptine]. / Crises convulsives révélant une angiopathie cérébrale du post-partum par prise de bromocriptine.

We report a case of postpartum convulsions due to a benign cerebral angiopathy occurring after bromocriptine therapy to suppress lactation. This case analyses the current knowledge concerning this rare entity. It allows pointing out special measures that must be taken with the administration of bromocriptine.

[Severe complications after a translaryngeal tracheotomy]. / Complication sévère après une trachéotomie translaryngée.

We report the case of a 71-year-old man receiving anticoagulant treatment because of a mechanical aortic valve. Because of an unsuccessful weaning after abdominal surgery, a translaryngeal tracheostomy was realised without incident. The patient died few days later after a hypoxic cardiac arrest due to a severe haemorrhage after the first recannulation. This case illustrates a severe complication because of the recannulation after a translaryngeal tracheostomy and how cautions one should be before realizing a percutaneous tracheostomy in a patient under anticoagulant treatment.

[Unusual complication after hip surgery under spinal anesthesia]. / Complication inattendue après chirurgie de hanche sous rachianesthésie.

The development of an acute respiratory distress syndrome following hip surgery in elderly patients is suggestive of thromboembolism in most instances. However, we must keep in mind the possibility of rarer complications, which can remain undiagnosed because they are hidden by prominent abnormal behaviours, which can develop following any type of anaesthesia. We report the case of a patient who developed a confusion following an orthopaedic surgery under spinal anaesthesia; this confusion concealed a penetration syndrome resulting from accidental inhalation of a dental crown. Because this patient was old and had previously developed chronic lung disorders, we selected a spinal anaesthesia for performing the surgery; these underlying respiratory disorders worsened the clinical consequences of the inhalation. The dental crown was removed under general anaesthesia with spontaneous ventilation using a bronchoscope after an unsuccessful attempt with a fibrescope due to the size of the foreign body.

Percutaneous tracheostomy by forceps dilation: report of 162 cases.

A prospective, observational clinical study evaluated the safety of percutaneous single-step dilatational tracheostomy over a 43-month period. One hundred and sixty-two patients were deemed suitable for the procedure. The mean duration of tracheal intubation prior to tracheostomy was 6 days. The mean duration of the procedure was 9.3 min. Intra-operative complications occurred in 27 patients (16.6%), most of which were minor technical difficulties without morbidity. Postoperative complications, some of which were associated with morbidity, occurred in 16 patients. There were two deaths secondary to premature decannulation, one case of severe bleeding and five pneumothoraces. Long-term complications were assessed in 81 patients; there were four tracheal stenoses requiring surgery or laser therapy and seven patients with granulation tissue at the stoma site which did not require treatment. Forceps dilatational percutaneous tracheostomy appeared to be a convenient bedside procedure. However, complications do occur and further studies should address late sequellae, such as tracheal stenosis.

[Anesthesia-resuscitation in war situations. Apropos of 43 cases]. / Anesthésie-réanimation en situation de guerre. A propos de 43 cas.

The work of a french field surgical hospital deployed in Bosnia-Herzegovina is described (Sarajevo, July 1993-November 1993). Forty three patients with acute war injuries were admitted. The patterns of wounding and the methods of casualties management are discussed with special considerations for fluid resucitation and autotransfusion.

[Right ventricular function: physiological and physiopathological features]. / Fonction ventriculaire droite: bases physiologiques et physiopathologiques.

Sinus and conus constitute the two cavities of the right ventricle. They are anatomically and functionally different. The sinus is a flow-generator and the conus a pressure-regulator. The coronary circulation of the right ventricle is provided by the right coronary artery and the left anterior descending artery. The right ventricle is perfused during systole and diastole. When oxygen demand increases, coronary arteries dilate and oxygen extraction rises. As for the left ventricle, right ventricular performance depends upon heart rate, rhythm, contractility and loading conditions. Ventricular interactions are very important for right ventricular function. Loading conditions and contractility of the left ventricle are of major significance for right ventricular performance. For the right ventricle, the end of the ejection is different from the end of the active contraction. The time between them allows to achieve ventricular emptying. This duration is linked to afterload. Presently, it is impossible to accurately and simply assess these conditions. Pressure and volume overloadings result in right ventricular failure. They are responsible for ventricular dilation and ischaemia with a decrease in cardiac output, generating a vicious circle. Treatment includes the removal of the cause, and the maintenance of systemic arterial pressure and biventricular contractility. It is difficult to assess the effects of intravenous vasodilators on right ventricular afterload.