[Beware of labels]. / 5 minutes pour apprendre. Gare aux étiquettes.

A 50-year-old individual identified as a 'frequent user' of emergency services due to chronic abdominal pain was transported to the emergency department by ambulance during a new episode of abdominal pain. Despite being initially deemed stable by paramedics, the patient was not reassessed by the triage nurse upon arrival. Subsequently, the patient presented with severe pain, arterial hypotension, and tachycardia. Following a multidisciplinary protocol for pain management, analgesic treatment was initiated. Despite several hours of management and repeated assessments, an abdominal CT-scan was eventually conducted, revealing a perforated small intestine. The application of the 'frequent user' label may have contributed to a delay in the provision of timely care for this patient.

[Chronic hiccups: diagnosis and treatment]. / Hoquet chronique : diagnostic et traitement.

Chronic hiccups, lasting more than 48 hours, are a medical condition that remains challenging in both diagnosis and treatment. They can be the sole symptom of a serious underlying disorder, and should therefore not be overlooked, although gastroesophageal reflux disease (GERD) constitutes their most prevalent cause. Chronic hiccups mandate a comprehensive etiological assessment. Treatment strategy may include physical, pharmacological and interventional approaches, as described in literature, particularly when direct causal treatment is unattainable.

Le hoquet chronique, de plus de 48 heures, est une entité dont la prise en charge est souvent méconnue. Il ne doit pas être négligé parce qu'il peut être le seul symptôme d'une maladie sous-jacente grave, même si le reflux gastro-œsophagien (RGO) en est la cause la plus fréquente. Face à un hoquet chronique, un bilan étiologique doit donc être effectué. Dans les cas où un traitement causal n'est pas envisageable, plusieurs possibilités de traitements physiques, médicamenteux et interventionnels sont décrites dans la littérature.

Development and validation of an assessment tool for adult simulated ultrasound-guided fascia iliaca block: a prospective monocentric study.

BACKGROUND: Fascia iliaca block (FIB) is an effective technique for analgesia. While FIB using ultrasound is preferred, there is no current standardised training technique or assessment scale. We aimed to create a valid and reliable tool to assess ultrasound-guided FIB. METHOD: This prospective observational study was conducted in the ABS-Lab simulation centre, University of Poitiers, France between 26-29 October and 14-17 December 2021. Psychometric testing included validity analysis and reliability between two independent observers. Content validity was established using the Delphi method. Three rounds of feedback were required to reach consensus. To validate the scale, 26 residents and 24 emergency physicians performed a simulated FIB on SIMLIFE, a simulator using a pulsated, revascularised and reventilated cadaver. Validity was tested using Cronbach's α coefficient for internal consistency. Comparative and Spearman's correlation analysis was performed to determine whether the scale discriminated by learner experience with FIB and professional status. Reliability was analysed using the intraclass correlation (ICC) coefficient and a correlation score using linear regression (R2). RESULTS: The final 30-item scale had 8 parts scoring 30 points: patient positioning, preparation of aseptic and tools, anatomical and ultrasound identification, local anaesthesia, needle insertion, injection, final ultrasound control and signs of local anaesthetic systemic toxicity. Psychometric characteristics were as follows: Cronbach's α was 0.83, ICC was 0.96 and R2 was 0.91. The performance score was significantly higher for learners with FIB experience compared with those without experience: 26.5 (22.0; 29.0) vs 22.5 (16.0; 26.0), respectively (p=0.02). There was a significant difference between emergency residents' and emergency physicians' scores: 20.5 (17.0; 25.0) vs 27.0 (26.0; 29.0), respectively (p=0.0001). The performance was correlated with clinical experience (Rho=0.858, p<0.0001). CONCLUSION: This assessment scale was found to be valid, reliable and able to identify different levels of experience with ultrasound-guided FIB.

No waiting lying in a corridor: a quality improvement initiative in an emergency department.

BACKGROUND: Overcrowding in the emergency department (ED) is a global problem and a source of morbidity and mortality and exhaustion for the teams. Despite multiple strategies proposed to overcome overcrowding, the accumulation of patients lying in bed awaiting treatment or hospitalisation is often inevitable and a major obstacle to quality of care. We initiated a quality improvement project with the objective of zero patients lying in bed awaiting care/referral outside a care area. METHODS: Several plan-do-study-act (PDSA) cycles were tested and implemented to achieve and especially maintain the goal of having zero patients waiting for care outside the ED care area. The project team introduced and adapted five rules during these cycles: (1) no patients lying down outside of a care unit; (2) forward movement; (3) examination room always available; (4) team huddle and (5) an organisation overcrowding plan. RESULTS: Adaptation of ED organisation in the form of PDSA cycles allowed to obtain a collective team dimension to patient flow management. Since December 2021, despite an increase in activity, no patient is placed in a lying-in waiting area outside a care zone, irrespective of their care level. Vital distress and fragile patients who need to be kept in a supine position are treated immediately. In 2022, waiting time before medical contact was <2 hours for 90% of all patients combined. CONCLUSIONS: The PDSA strategy based on these five measures allowed to remove in-house obstacles to the internal flow of patients and to fight against their installation outside the care area. These measures are easily replicable by other management teams. Quality indicators of EDs are often heterogeneous, but we propose that the absence of patients lying on a stretcher outside a care area could be part of these indicators, and thus contribute to the improvement and safety of care provided to all patients.

[Access to health care for vulnerable migrants in Switzerland, all equal?] / Accès aux soins des migrants en situation de vulnérabilité en Suisse, tous égaux ?

Switzerland, after having been a nation of emigration for a long time, has seen its situation reversed with the industrial revolution and a succession of international crises responsible for several waves of migration. Some of these immigrants have health needs that vary according to their country of origin and their migratory route. Due to communication difficulties or legal issues, they do not always have access to appropriate health care. Although Switzerland tries to provide a framework and coordinate the care pathway, inequalities persist. Good information for professionals and patients, the use of trained interpreters and knowledge of local structures to which these patients can be referred might improve the situation.

La Suisse, après avoir longtemps été une nation d'émigration, a vu ses courants migratoires s'inverser avec la révolution industrielle et une succession de crises internationales responsables de plusieurs vagues migratoires. Certains de ces immigrants sont en situation de vulnérabilité et ont des besoins en santé variables selon leur pays d'origine et leur parcours. Du fait de difficultés de communication ou d'aspects légaux, ils ne bénéficient pas toujours d'un accès aux soins adapté. Bien que la Suisse tente d'encadrer et de coordonner les parcours de soins de ces populations à l'aide d'outils et de structures d'accueil, des inégalités persistent. Une bonne information des professionnels et des patients, le recours à des interprètes formés et la connaissance des structures locales vers lesquelles adresser ces patients peuvent améliorer la situation.

[Artificial Intelligence (AI): keep it under control]. / 5 minutes pour apprendre. Intelligence artificielle (IA) : gardons le contrôle.

In recent years, artificial intelligence (AI) has become increasingly important in our healthcare systems and in patient care. Several programs are now able to detect and localize fractures on conventional X-rays. Studies show that coupled with human interpretation, these software programs improve diagnostic performance and reduce healthcare costs. However, they are not infallible (variable specificity and sensitivity according to studies). This article shows through a clinical case the challenges and analytical biases of AI in the diagnostic process.

The Effect of Positive Therapeutic Communication on Pain (POPAIN) and Anxiety During Arterial Blood Gas Standardized Procedures in the Emergency Department Compared to Traditional Communication: Protocol for a Monocentric Randomized Controlled Trial.

BACKGROUND: In the emergency department (ED), medical procedures, such as arterial blood gas (ABG) testing, can cause pain and high stress levels. However, ABG testing is a routine procedure assessing the severity of the patient's condition. To reduce the pain of ABG, several methods have been investigated without significant difference in pain perception. Communication, a key element of care, has shown a significant effect on pain perception. A positive communication strategy, including positive, kind, or reassuring words, can reduce pain perception, while negative words can raise this perception, causing discomfort, known as the "nocebo effect." Although some studies have compared the impact of verbal attitudes, particularly in anesthesia and mainly with staff already trained in hypnosis, to the best of our knowledge, none have investigated the effect of communication in the emergency setting, where patients may be more suggestible to the words used. OBJECTIVE: In this study, we will investigate the effect of positive therapeutic communication on pain, anxiety, discomfort, and global satisfaction in patients requiring ABG compared to nocebo and neutral communication. METHODS: A single-center, double-blind randomized controlled trial (RCT) with 3 parallel arms will be conducted with 249 patients requiring ABG during their ED visit. Patients will be randomly assigned to 1 of 3 groups before receiving ABG: positive communication group, negative communication (nocebo) group, or neutral communication (neutral) group. The communication and the words used by the physicians during hygiene preparation, artery location, and puncture will be imposed in each group. The study will be proposed to each patient corresponding to the inclusion criteria. The physicians will not be trained in hypnosis or in positive therapeutic communication. The procedure will be recorded with audio recorders to test its quality. Intention-to-treat analysis will be performed. The primary endpoint is the onset of pain. The secondary outcomes are patient comfort, patient anxiety, and global satisfaction of the patient with the communication strategy used. RESULTS: On average, 2000 ABG procedures are performed each year in the EDs of hospitals. In this study, 249 patients are expected to be included. With a projected positive response rate of 80%, we intend to include 25 (10%) patients per month. The inclusion period began in April 2023 and will run until July 2024. We hope to publish the results of the study during the fall of 2024. CONCLUSIONS: To the best of our knowledge, this study is the first RCT assessing the use of positive communication on pain and anxiety in patients undergoing the ABG procedure in the ED. A reduction in pain, discomfort, and anxiety is expected when using positive communication. If the results are positive, this could be useful to the medical community and encourage clinicians to monitor their communication during care. TRIAL REGISTRATION: ClinicalTrials.gov NCT05434169; https://clinicaltrials.gov/ct2/show/NCT05434169. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/42043.

Bleeding on oral anticoagulants: overview of reversal strategies.

Oral anticoagulants (antivitamin K, direct oral anticoagulants) are routinely prescribed for the prevention or treatment of thromboembolic events, and many patients are now on long-term anticoagulant therapy. However, this complicates the management of urgent surgical conditions or major bleeding. Various strategies have been developed to reverse the anticoagulant effect and this narrative review provides an overview of the wide range of therapies currently available.

[Complications of cerebral ventricular shunts]. / Complications des dérivations ventriculaires internes.

Internal ventricular shunts are systems for draining excess cerebrospinal fluid to another body cavity in patients with hydrocephalus. They are subject to complications that are sometimes difficult to identify and can lead to diagnostic errors if practitioners are not enough aware. The most frequent complications are mechanical (drainage dysfunction) and infectious. Interruption of the drainage may causeneurological signs of intracranial hypertension; the diagnosis is usually easy. However, the clinical signs can sometimes be less obvious, and a dysfunction of the shunt should be evoked. A multidisciplinary management with the neurosurgery team is necessary to evaluate the appropriate investigation and the emergency management.

Les dérivations ventriculaires internes sont des systèmes permettant de drainer l'excès de liquide céphalorachidien vers une autre cavité du corps chez des malades atteints d'hydrocéphalie. Elles font l'objet de complications parfois difficiles à identifier pouvant conduire à des errances diagnostiques si les praticien-ne-s n'y sont pas sensibilisé-e-s. Les complications les plus fréquentes sont mécaniques avec dysfonctionnement du drainage et infectieuses. L'arrêt du drainage peut provoquer des signes neurologiques d'hypertension intracrânienne ; le diagnostic est alors souvent aisé. Cependant, les signes cliniques peuvent être parfois plus subtils et un dysfonctionnement de la dérivation doit être évoqué. Une prise en charge pluridisciplinaire avec l'équipe de neurochirurgie est nécessaire afin d'évaluer les investigations et la conduite à tenir en urgence.

Implementation of a Novel Concept of Emergency Department Management: e-Boss.

Hospital-based emergency services are frequently criticized worldwide for their management, which can lead to a decrease in staff motivation, with a potential impact on patient safety. This article describes how harnessing the power of social networks can facilitate the management of emergency department teams. Beyond teaching, promoting emergency medicine and recruiting health professionals, these tools can unite employees around a virtual leader and help develop a true service culture. The concept of management through social networks is a novel manner to reach out to staff and should be further explored for use in the health care context.

Paramedics in Switzerland: A Mature Profession.

This paper describes how the profession of paramedics has evolved in Switzerland and takes the perspective of public health. Ambulance drivers play an important role in the health system, not only as a response to emergencies, but also by working in an interprofessional and interdisciplinary manner in response to other public health needs, such as home care, triage, telemedicine and interhospital transfers. This pre-hospital system is rapidly evolving and relies on the work of paramedics.

Blood Transfusion Reactions-A Comprehensive Review of the Literature including a Swiss Perspective.

Blood transfusions have been the cornerstone of life support since the introduction of the ABO classification in the 20th century. The physiologic goal is to restore adequate tissue oxygenation when the demand exceeds the offer. Although it can be a life-saving therapy, blood transfusions can lead to serious adverse effects, and it is essential that physicians remain up to date with the current literature and are aware of the pathophysiology, initial management and risks of each type of transfusion reaction. We aim to provide a structured overview of the pathophysiology, clinical presentation, diagnostic approach and management of acute transfusion reactions based on the literature available in 2022. The numbers of blood transfusions, transfusion reactions and the reporting rate of transfusion reactions differ between countries in Europe. The most frequent transfusion reactions in 2020 were alloimmunizations, febrile non-hemolytic transfusion reactions and allergic transfusion reactions. Transfusion-related acute lung injury, transfusion-associated circulatory overload and septic transfusion reactions were less frequent. Furthermore, the COVID-19 pandemic has challenged the healthcare system with decreasing blood donations and blood supplies, as well as rising concerns within the medical community but also in patients about blood safety and transfusion reactions in COVID-19 patients. The best way to prevent transfusion reactions is to avoid unnecessary blood transfusions and maintain a transfusion-restrictive strategy. Any symptom occurring within 24 h of a blood transfusion should be considered a transfusion reaction and referred to the hemovigilance reporting system. The initial management of blood transfusion reactions requires early identification, immediate interruption of the transfusion, early consultation of the hematologic and ICU departments and fluid resuscitation.

[Demystifying the intraosseous infusion technique]. / Tous les secrets de l'accès vasculaire intra-osseux.

Intraosseous infusion provides a safe and effective access to the vascular system that allows for administration of urgent therapies in both adults and children. It has few contraindications and complications are rare. The needle is most commonly inserted in the proximal tibia or anterior humerus. Different devices are available but those with a traditional drill are the most widespread. The intraosseous infusion procedure is easy and the learning curve is short, making it the best alternative when traditional intravenous access is not possible or delayed.

Le cathétérisme intra-osseux permet un accès vasculaire rapide, facile, sûr et efficace pour l'administration de thérapeutiques urgentes, chez l'enfant comme chez l'adulte. Il présente peu de contre-indications et ses complications sont rares. Les sites d'implantation privilégiés sont les abords tibial proximal et huméral chez l'adulte. Différents systèmes de cathétérisme sont disponibles ; les plus répandus et probablement les plus simples d'utilisation sont maintenant motorisés. La technique d'utilisation de ces cathéters est facilement acquise après une courte formation. Ils représentent la première alternative à l'accès veineux périphérique dans la gestion des urgences vitales lorsque celui-ci n'est pas disponible.