Emergency Resuscitation Research Articles

Life-threatening hypotension in the immediate postoperative period of cataract surgery under topical anesthesia: a report of two cases

BackgroundCataract surgery is one of the most frequent surgeries in the world. It is a very safe procedure mostly performed under topical anesthesia in outpatients centers. Due to the growing lack of anesthesiologists, cataract surgeries are more frequently performed without an anesthesiologist present in the operating room. Although extremely rare, life-threatening complications may occur.Cases presentationWe report two cases of cataract surgery complicated by severe hypotension that required emergency resuscitation in the immediate postoperative period and hospitalization in intensive care unit. Anaphylactic shock was confirmed in the first case and suspected in the second.Conclusions and importanceEven though cataract surgery is a very safe procedure, it is essential to ensure the presence of an anesthesiologist to manage potential, though extremely rare, life-threatening complications such as anaphylactic reactions.

Apnea caused by retrobulbar anesthesia: A case report

Apnea caused by retrobulbar anesthesia is a very rare but severe complication during ophthalmic surgery. We report a rare case of apnea caused by retrobulbar anesthesia, and emergency resuscitation was used. A 74-year-old female patient was diagnosed with rhegmatogenous retinal detachment in the right eye and planned to undergo vitrectomy under retrobulbar anesthesia. After the retrobulbar anesthesia in her right eye, she became unconscious and apneic. It was suggested that she had developed brainstem anesthesia. Assisted ventilation was initiated. Atropine 0.5 mg, epinephrine 1 mg, ephedrine 30 mg, and lipid emulsion were given. Five minutes later, her consciousness and breathing gradually returned, but with uncertain light perception in her right eye. Alprostadil 20 µg was given, and after 2 h her visual acuity resumed to the preoperative level. Brainstem anesthesia is a serious complication secondary to retrobulbar anesthesia. Medical staff should pay attention to the identification of brainstem anesthesia and be familiar with the emergency treatment for this complication.

Maternal and perinatal health in undocumented migrants: estimating access and outcomes through HMIS

Abstract Background Vulnerability and inequality are exacerbated in undocumented migrants, the most invisible to health systems. Objectives To estimate maternal and perinatal health needs in undocumented migrants and test a methodology for systematic monitoring & evaluation. Methods Population-based retrospective cohort study based on routine data through maternity records and temporary registration code in a sub-national Health Management Information System. Results 420924 deliveries including 1524 undocumented migrants having accessed maternity care through the NHS in Lombardy Region (Italy) from 2016 to 2021 were included. Demographics and social determinants: undocumented migrants were born in Europe (non-EU) (36%), Americas (30%), Africa (6%), Western Pacific (3%), South-East Asia (2%), Italy (2%), were stateless (7%); 52% had no/low schooling, 92% were unemployed and 52% non-married, compared to 15%, 20%, and 44% Italians. Obstetric history and antenatal care: 22% undocumented migrants had a previous abortion and 15% a previous cesarean delivery; 58% had ≥5 antenatal visits, 67% first ANC visit in trimester 1, 64% ≥ 2 ultrasounds incl. first in trimester 1, 6% full laboratory tests, compared to 90%, 97%, 97%, and 66% Italians. Intra-partum and perinatal care: 45% undocumented migrants delivered in a public hospital with neonatal intensive care unit; 69% had a normal delivery, 5% instrumental delivery, 10% and 27% emergency and total cesarean section; 2.6% neonates had emergency resuscitation and 49% were breastfed <2h from birth. Outcomes: 81% physiological pregnancies, 2.3% severe hemorrhage, 4.8% intra-uterine growth retardation, 9.3% pre-term delivery, 17% small for gestational age, 7% low birth weight, 0.6% poor Apgar score, 3% malformations. Conclusions Maternal and perinatal health was poor in undocumented migrants, varying by birthplace. Social determinants, health coverage and outcomes showed vulnerability and inequality compared to the general population. Key messages • Tailored interventions are needed: outreach health promotion on safe motherhood and neonatal care, healthcare provider training, cultural mediation, translation, and functional language learning. • A systematic monitoring and evaluation system needs to routinely collect, integrate, and analyze data on key indicators.

Therapeutic Doctors` Competency during the Providing Emergency Medical Care at the Scene

During the last years it has been observed the worldwide trend in regular creation, upgrading and implementation of emergency care protocols at the prehospital stage in the medical practice. The huge role is given to the methods of doctors` simulation preparedness in case of the emergency care at the scene. Modern doctors` preparedness requires practicing of the resuscitation in the simulation centers on the specific dummies or devices without the risk of making any harm to the patient, developing the ability to make quick and correct decision and conduct all necessary manipulations and interferences without any mistake. According to the professional literature, it is usually observed the lack of practical skills concerning the emergency care at the scene of an accident among therapeutic doctors`. Nowadays, one of the most important task undergraduate and postgraduate medical educations is the creation of simulation centers for quality training of highly qualified specialists, including emergency medical care.
 The aim of given investigation is the evaluation of the professional therapeutic doctors` competency in providing emergency medical care at the scene in accordance to the latest recommendations of the European Resuscitation Council (2021) and American Heart Association (2020). According to tests conducted in the 2017-2018s among therapeutic doctors about their abilities of the resuscitation conducting, it was revealed that only 52% were able to diagnose the state of clinical death; 63% - were able to perform chest compression; 15% were able to provide opening of airways; extremely low was the numbers of those who were able to use AED and ventilation – 5% and 9% correspondently. Therefore, one of the key tasks of the modern medical simulative education is to prepare therapeutic doctors to be able to perform emergency resuscitation at the scene.
 Key words. Simulative medicine, emergency medical care, the scene of an accident, therapeutic doctors.

National Survey: How Do We Approach the Patient at Risk of Clinical Deterioration outside the ICU in the Spanish Context?

Background: Anticipating and avoiding preventable intrahospital cardiac arrest and clinical deterioration are important priorities for international healthcare systems and institutions. One of the internationally followed strategies to improve this matter is the introduction of the Rapid Response Systems (RRS). Although there is vast evidence from the international community, the evidence reported in a Spanish context is scarce. Methods: A nationwide cross-sectional research consisting of a voluntary 31-question online survey was performed. The Spanish Society of Intensive, Critical and Coronary Care Medicine (SEMICYUC) supported the research. Results: We received 62 fully completed surveys distributed within 13 of the 17 regions and two autonomous cities of Spain. Thirty-two of the participants had an established Rapid Response Team (RRT). Common frequency on measuring vital signs was at least once per shift but other frequencies were contemplated (48.4%), usually based on professional criteria (69.4%), as only 12 (19.4%) centers used Early Warning Scores (EWS) or automated alarms on abnormal parameters. In the sample, doctors, nurses (55%), and other healthcare professionals (39%) could activate the RRT via telephone, but only 11.3% of the sample enacted this at early signs of deterioration. The responders on the RRT are the Intensive Care Unit (ICU), doctors, and nurses, who are available 24/7 most of the time. Concerning the education and training of general ward staff and RRT members, this varies from basic to advanced and specific-specialized level, simulating a growing educational methodology among participants. A great number of participants have emergency resuscitation equipment (drugs, airway adjuncts, and defibrillators) in their general wards. In terms of quality improvement, only half of the sample registered RRT activity indicators. In terms of the use of communication and teamwork techniques, the most used is clinical debriefing in 29 centers. Conclusions: In terms of the concept of RRS, we found in our context that we are in the early stages of the establishment process, as it is not yet a generalized concept in most of our hospitals. The centers that have it are in still in the process of maturing the system and adapting themselves to our context.

Prone cardiopulmonary resuscitation: an intensive care unit case series

Background: Critically ill patients frequently receive mechanical ventilation in the prone position. If hypoxic respiratory failure progresses, pulseless events requiring emergent cardiopulmonary resuscitation may occur. Administering cardiopulmonary resuscitation in the prone position provides an opportunity to initiate chest compressions quickly, eliminating delays in resuscitative efforts.

35.2 Pediatric Emergency Medicine Perspective

Pediatric emergency medicine (PEM) providers are trained to identify and address emergencies, and the mental health crisis is worthy of an emergent resuscitation through a team of clinical and nonclinical stakeholders. This presentation will share the perspectives of PEM clinicians and the opportunities for collaboration and effective change through a multidisciplinary approach.

Analysis of the Clinical Characteristics and Disease Spectrum of the Aged Patients in Emergency Resuscitation Room

Objectives: To understand the clinical characteristics and disease spectrum of the aged patients in emergency resuscitation room (RR). Methods: The data of patients aged 60 years or over in the emergency resuscitation room in Shanghai Fifth People’s Hospital, Fudan University from September 2020 to August 2021 were collected and retrospectively analyzed in terms of the demographic characteristics, duration of visit, type of disease, duration of stay in the emergency resuscitation room and prognosis. Results: The mean age of the patients was [Formula: see text] years, the patients aged from 80 years to 89 years were the most common (35.46%). The most frequent time period of visiting the emergency resuscitation room was 8–12[Formula: see text]AM (27.66%). The most common diseases were neurological diseases (31.40%), cardiovascular diseases (30.68%) and respiratory diseases (11.31%). The spectrum of diseases with the highest mortality included sudden death and agnogenic disorders (29.35%), advanced tumors (25.27%), followed by neurological diseases (7.23%). The patients with advanced tumor had the longest duration of stay time ([Formula: see text][Formula: see text]h) in the emergency resuscitation room. The difference of ages, the proportion of visiting times and the duration of stay between male and female patients in the emergency resuscitation room did not show statistical significance ([Formula: see text]), but the difference of types of disease between males and females was significant ([Formula: see text]). Conclusion: The clinical characteristics, visiting time and disease spectrum of the elderly patients in emergency resuscitation room show certain characteristics. Our finding highlights that understanding these characteristics is beneficial to the better treatment for the elderly patients in the resuscitation room.

Ruptured splenic artery aneurysms in pregnancy and usefulness of endovascular treatment in selective patients: A case report and review of literature

BACKGROUNDThe rupture of a splenic artery aneurysm (SAA) in pregnancy is an uncommon condition. However, it is associated with high mortality rates in pregnant women and fetuses even after surgical treatment. Though the endovascular treatment of SAAs is currently preferred as it can improve the outcomes even in emergent cases, the endovascular treatment of a ruptured SAA during pregnancy has not been reported until date.CASE SUMMARYWe report a case of a 33-year-old woman with the sudden onset of epigastric pain due to a ruptured SAA at the mid-portion of the splenic artery at 18 wk of pregnancy. After emergent initial resuscitation, the patient was diagnosed with a ruptured SAA through digital angiography. Immediately upon diagnosis, she underwent emergent endovascular embolization of the splenic artery for the rupture on the spot. Next, surgery was performed to remove the hematoma under stable conditions. Although the fetus was found to be dead during resuscitation, the woman recovered without complications and was discharged 15 d postoperatively.CONCLUSIONEndovascular treatment might be a valuable alternative to surgery/lead to safer surgery for selected pregnant patients with ruptured SAAs.

Implementation and facilitation of post-resuscitation debriefing: a comparative crossover study of two post-resuscitation debriefing frameworks

BackgroundPost-resuscitation debriefing (PRD) is the process of facilitated, reflective discussion, enabling team-based interpersonal feedback and identification of systems-level barriers to patient care. The importance and benefits of PRD are well recognized; however, numerous barriers exist, preventing its practical implementation. Use of a debriefing tool can aid with facilitating debriefing, creating realistic objectives, and providing feedback.ObjectivesTo assess utility of two PRD tools, Debriefing In Situ Conversation after Emergent Resuscitation Now (DISCERN) and Post-Code Pause (PCP), through user preference. Secondary aims included evaluating differences in quality, subject matter, and types of feedback between tools and implications on quality improvement and patient safety.MethodsProspective, crossover study over a 12-month period from February 2019 to January 2020. Two PDR tools were implemented in 8 week-long blocks in acute care settings at a tertiary care children’s hospital. Debriefings were triggered for any intubation, resuscitation, serious/unanticipated patient outcome, or by request for distressing situations. Post-debriefing, team members completed survey evaluations of the PDR tool used. Descriptive statistics were used to analyze survey responses. A thematic analysis was conducted to identify themes that emerged from qualitative responses.ResultsA total of 114 debriefings took place, representing 655 total survey responses, 327 (49.9%) using PCP and 328 (50.1%) using DISCERN. 65.2% of participants found that PCP provided emotional support while only 50% of respondents reported emotional support from DISCERN. PCP was found to more strongly support clinical education (61.2% vs 56.7%). There were no significant differences in ease of use, support of the debrief process, number of newly identified improvement opportunities, or comfort in making comments or raising questions during debriefs between tools. Thematic analysis revealed six key themes: communication, quality of care, team function & dynamics, resource allocation, preparation and response, and support.ConclusionBoth tools provide teams with an opportunity to reflect on critical events. PCP provided a more organized approach to debriefing, guided the conversation to key areas, and discussed team member wellbeing. When implementing a PRD tool, environmental constraints, desired level of emotional support, and the extent to which open ended data is deemed valuable should be considered.

Resuscitative events in a level 4 NICU: Prevalence, characteristics, and outcomes of compressive versus non-compressive events.

Little is known about the prevalence, characteristics, and outcomes of neonates needing emergent resuscitation within the level 4 neonatal intensive care units (NICU). Clinical factors prior to and following resuscitation event or characteristics of those who require chest compressions versus those without compressions has not been previously delineated. The aim of this study is to describe characteristics and outcomes of neonates who have compressive vs. non-compressive resuscitative events. Retrospective observational study of neonates with a resuscitative event in the Children's Mercy Hospital level 4 NICU between January 2012 and April 2017. Data were derived from the NICU Code Blue database and the electronic medical record. Primary outcome was survival to hospital discharge. Of the 641 resuscitative events, most were in the non-compressive group (n = 481). Those requiring chest compressions longer than 1 minute had significantly different clinical characteristics and decreased survival. There was no difference between groups in gestational age or birth weight. Non-compressive events are more common in the NICU setting than are compressive events. Neonates requiring chest compressions longer than 1 minute are more likely to have a higher respiratory severity score, need for vasopressors, worse renal function post-event, and decreased survival to discharge.

Applying the Haddon Matrix to Frontline Care Preparedness and Response in Asymmetric Warfare.

Asymmetric warfare and the reaction to its threats have implications in the way far-forward medical assistance is provided in such settings. Investments in far-forward emergency resuscitation and stabilization can contribute to saving lives and increase the resilience of health systems. Thus, it is proposed to extend the use of the Haddon Matrix to determine a set of strategies to better understand and prioritize activities to prepare for and set-up frontline care in the form of Trauma Stabilization Points (TSPs). An expert consensus methodology was used to achieve the research aim. A small subject matter experts' group was convened to create and validate the content of the Haddon Matrix. The result of the expert group consultations presented an overview of TSP Preparedness and Operational Readiness activities within a Haddon Matrix framework. Main strategies to be adopted within the cycle from pre- to post-event had been identified and presented considering the identified opportunities in the context of the possibility of implementation. Of particular importance was the revision of a curriculum that fits the civilian medical system and facilitates its adaptation to the context and available resources. The new framework to enhance frontline care preparedness and response using the Haddon Matrix facilitated the identification of a set of strategies to support frontline health care workers in a more efficient manner. Since the existing approach and tools are insufficient for modern warfare, additional research is needed.

“These Are Our Kids”: Qualitative Interviews With Clinical Leaders in General Emergency Departments on Motivations, Processes, and Guidelines in Pediatric Sepsis Care

Sepsis is a leading cause of pediatric death requiring emergency resuscitation. Most children with sepsis are treated in general emergency departments (EDs); however, research has focused on pediatric EDs. We sought to identify barriers and facilitators to pediatric sepsis care in general EDs, including care processes, the role of guidelines, and incentivized metrics. In this qualitative study, we conducted semistructured interviews with key informant physician and nurse leaders overseeing pediatric sepsis in general EDs in 2021, including medical directors, nurse managers, and quality coordinators. Interviews were audio-recorded, transcribed, and coded using deductive domains based on steps of sepsis care, pediatric readiness, and structural dynamics. Domains were analyzed across interviews in matrices, using thematic analysis within domains. Twenty-one clinical leaders representing 26 hospitals, including trauma levels I to IV, were interviewed. The themes included the following: (1) motivation to improve pediatric sepsis care based on moral imperative and location; (2) need for actionable pediatric sepsis guidelines; (3) children's hospitals' role in education, protocols, transfer, and consultation; and (4) mixed feelings about reportable metrics, particularly in EDs with low pediatric volume. Sepsis care process challenges included diagnosis, intravenous access, and antibiotic delivery but varied among hospitals. Leaders in general EDs were motivated to provide high-quality pediatric sepsis care but disagreed on whether reportable metrics would drive improvements. They universally sought direct support from their nearest children's hospitals and actionable guidelines. Efforts to address pediatric sepsis quality in general EDs should prioritize guideline design, responsive pediatric transfer and consultation systems, and locally specific process improvement.

Social Work and the Acute Psychosocial Care of Families in Pediatric Resuscitation Settings: A Single-Site Clinical-Data Mining Study

ABSTRACT Purpose Family attendance in pediatric resuscitation situations is currently accepted practice within modern emergency departments. The support of these families has become a key area of practice for emergency department social workers. However, there is limited evidence to guide acute psychosocial care of families who find themselves in these situations. Method This practice-based research project used a clinical data-mining methodology. Descriptive and inferential analyses of the demographic characteristics and documented psychosocial care needs of 1123 families whose child were cared for in a major pediatric hospital resuscitation area was undertaken, with particular focus on available social work referral and intervention data. Results Results included family demographic, psychosocial care need and the social work role information. We identify factors impacting on family care needs, social work intervention and service pathways for this population. Conclusion A skill set for social work clinicians working in pediatric emergency resuscitation settings is proposed.

A Simulation Study Using a Quality Cardiopulmonary Resuscitation Medical Manikin to Evaluate the Effects of Using Personal Protective Equipment on Performance of Emergency Resuscitation by Medical Students from the University of Silesia, Katowice, Poland and Non-Medical Personnel.

BackgroundDuring the Coronavirus disease 2019 (COVID-19) pandemic, personal protective equipment (PPE) is used during medical resuscitation aerosol-generating procedures (AGP). This simulation study aimed to evaluate the effects of PPE on the performance of emergency resuscitation by medical students from the University of Silesia, Katowice, Poland and non-medical personnel, and used a quality cardiopulmonary resuscitation (Q-CPR) medical manikin.Material/MethodsA simulation study was conducted using the Resusci Anne quality cardiopulmonary resuscitation (Q-CPR) medical manikin (Laerdal Medical AS, Norway). Participants were divided into 2 groups: a medical group of 50 and a non-medical group of 52, matched in pairs. Each pair performed 10 min of manual CPR with a compression-ventilation ratio of 30: 2 wearing PPE for AGP. The reference method was manual CPR wearing casual clothes along with surgical masks and latex gloves. Data about compression and ventilation were gathered using the QCPR Training application from Laerdal Medical.ResultsData analyses indicated statistically significant differences between medical students using PPE for AGP and basic protection: average rate of chest compressions (123 vs 114 per min; P=0.004), chest recoil (69 vs 93; P=0.0050, correct depth of chest compressions (86.5 vs 97; P=0.0081), quality of ventilation (85 vs 89; P=0.0041). Among non-medical personnel however, a statistically significant difference was in the quality of ventilation (69–85.5; P=0.0032).ConclusionsThe findings from this study showed that the use of PPE for AGP during CPR was associated with slower average speed of chest compressions, less chest recoil, incorrect depth of chest compressions, and lower quality of ventilation.

A 10-year bibliometric analysis of publications in emergency medicine

ObjectiveEmergency medicine (EM) research is growing at a rapid pace. It is important to understand the scope and trends over time in order to identify gaps and future areas for growth. This study aimed to describe trends in scientific publications within EM over the past decade. MethodsWe searched the Web of Science database's Emergency Medicine category for all scientific publications published between 2010 and 2019. Data were presented via descriptive statistics. Inferential bibliometric analyses included clustering of the selected parameters of keywords, Keyword Plus, titles, and abstracts; Bradford's law to evaluate core journals, and the Sankey diagrams to evaluate the flows between research themes over time. ResultsWe identified 32,858 articles written by 85,693 authors. The mean citations per document were 11. The top five countries with the highest number of publications were the United States (n = 42,221), Turkey (n = 6595), Canada (n = 6545), Australia (n = 5867), and China (n = 5322). The journals with the highest number of publications: the American Journal of Emergency Medicine, Journal of Emergency Medicine, Resuscitation, and Pediatric Emergency Care. The most frequent topics were cardiovascular emergencies, resuscitation, mortality, patient outcomes, emergency imaging, triage, education, and management. ConclusionThis bibliometric study is a quick snapshot of research in the EM field in the last decade and may provide insights into the scientific agendas of the EM professionals.

National Emergency Resuscitation Airway Audit (NERAA): a pilot multicentre analysis of emergency intubations in Irish emergency departments

BackgroundThere is paucity of literature on why and how patients are intubated, and by whom, in Irish Emergency Departments (EDs). The aim of this pilot study was to characterise emergency airway management (EAM) of critically unwell patients presenting to Irish EDs.MethodsA multisite prospective pilot study was undertaken from February 10 to May 10, 2020. This project was facilitated through the Irish Trainee Emergency Research Network (ITERN). All patients over 16 years of age requiring EAM were included. Eleven EDs participated in the project. Data recorded included patients’ demographics, indication for intubation, technique of airway management, medications used to facilitate intubation, level of training and specialty of the intubating clinician, number of attempts, success/complications rates and variation across centres.ResultsOver a 3-month period, 118 patients underwent 131 intubation attempts across 11 EDs. The median age was 57 years (IQR: 40–70). Medical indications were reported in 83% of patients compared to 17% for trauma. Of the 118 patients intubated, Emergency Medicine (EM) doctors performed 54% of initial intubations, while anaesthesiology/intensive care medicine (ICM) doctors performed 46%. The majority (90%) of intubating clinicians were at registrar level. Emergency intubation check lists, video laryngoscopy and bougie were used in 55, 53 and 64% of first attempts, respectively. The first pass success rate was 89%. Intubation complications occurred in 19% of patients. EM doctors undertook a greater proportion of intubations in EDs with > 50,000 attendance (65%) compared to EDs with < 50,000 attendances (16%) (p < 0.000).ConclusionThis is the first study to describe EAM in Irish EDs, and demonstrates comparable first pass success and complication rates to international studies. This study highlights the need for continuous EAM surveillance and could provide a vector for developing national standards for EAM and EAM training in Irish EDs.

EMS Use and Success Rates of Intraosseous Infusion for Pediatric Resuscitations: A Large Regional Health System Experience

Objective Access of intraosseous (IO) compartments is a commonly used technique that is an invaluable asset in emergency resuscitation. Prehospital IO success rates using semi-automatic insertion devices vary between 70 and 100% of pediatric patients. There are limited data on time to insertion and duration of IO function in the prehospital setting. Recent studies limited to the pediatric emergency department (PED) setting have also suggested that IOs may be less successful in the infant population. We explored the use of IO access for pediatric resuscitation, encompassing the prehospital and pediatric emergency department (PED) settings. Methods This is a retrospective review of emergency medical services (EMS) patient care reports and PED data of patients aged 0–17 years old and transported by regional ground EMS agencies in Southwestern Ontario, Canada from 2012 to 2019. Mean and median time to first insertion and IO function (from insertion to IO failure, IV access, transfer to ICU, or death) were calculated. Results Successful prehospital IO access was achieved in 83.7% of patients. The median time required to achieve IO access was 4 min (IQR 3-7) and mean duration of IO function was 27.6 min (SD: 14.8). Patients less than 1 year old had fewer functional IOs (25.9% vs. 75.0%), more insertion attempts (2 vs. 1), and shorter duration of IO function (18.8 vs. 32.2 mins) than the older age group (p < 0.05). Conclusions This is the first study to provide time to IO access and IO duration in the prehospital setting, and the first prehospital evidence to suggest inferior IO function in infants <1 year old, compared to other ages. This highlights unique challenges for infants that have implications for the PED, interfacility transport, and critical care settings.

Détresse et résilience des étudiants en médecine de Paris-Saclay lors de la première vague de la pandémie de COVID-19

ObjectivesIn France, during the first wave of the COVID-19 pandemic, all care workers have been mobilized. Despite this, the strong demand for care has put the health system under great strain. To overcome this overload of world, 86 medical students of Paris-Saclay University came to help some hospital services. They replaced caregivers, nurses or stretcher bearers under “degraded care” conditions. At the university level, the closure of the faculty due to generalized lockdown disrupted the training of these future doctors who were in second, third or fourth year of training (pre-clinical). This exploratory study proposes to collect the impact of the experience of these students during the first wave of the pandemic in order to better understand the difficulties they encountered, as well as the resources they exploited during this period. Materials and methodsUsing a mixed approach, both quantitative on the one hand and qualitative on the other hand, medical students from Paris-Saclay were interviewed through a retrospective questionnaire distributed in December 2020. The quantitative part of the questionnaire assessed their psychological distress (6-item Kessler scale) and their resilience (Brief Resilience Scale). The qualitative part of the questionnaire included various open questions concerning the motivations to participate, the difficulties encountered, the impact of the situation on their interpersonal relationships or their university course. ResultsA total of 46 responses from medical students from the University of Paris-Saclay were collected. This constitutes a response rate of 55%. Half of them were second or third year medical students. They were assigned to emergency departments, resuscitation or units dedicated to the care of patients with COVID-19. The average psychological distress score is 7.13. The average resilience score is 3.14. From these results, several categories of students were analyzed according to the elements found in their answers to the open questions. Almost all the students reported wanting to contribute to the collective effort and help hospital services. For some students, it was also a way of making themselves useful while escaping lockdown. The students were exposed to difficult working conditions, the distress of families and the deaths of numerous patients. Their involvement also had an impact on their relationships with their families: they could feel more isolated, or be afraid of infecting them. Their university work was very disrupted by their investment in the hospital: fatigue, concentration problems, lack of motivation could lead them to a form of dropping out of university. ConclusionsThe results of this study are part of the context of a particular health crisis. They show medical students exposed to significant psychosocial risks in a period of stress. It seems important to identify what leads some students to develop good resilience capacities. The COVID-19 pandemic acts as an indicator of difficulties that were already present but that it is exacerbating: the link between the faculty, the student and the hospital, mentoring, supervision, support, university workload, hospital working conditions, psycho-pedagogical support for students and support for most struggling students… These results invite us to rethink the educational engineering of medical studies so that they make it possible, even in a health crisis, to ensure the quality of training and the quality of life of medical students.

Determining resuscitation outcomes in combat casualties: Design of the Deployed Hemostatic Emergency Resuscitation of Traumatic Exsanguinating Shock (Deployed HEROES) study.

During the course of the recent conflicts, the recommendations for resuscitation practices have evolved, but there has been no comprehensive comparative effectiveness study of these resuscitation strategies. The objective of this study was to describe the development and study design of the Deployed Hemostatic Emergency Resuscitation of Traumatic Exsanguinating Shock (Deployed HEROES) study-the first comprehensive analysis of military resuscitation practices in the deployed environment from October 2001 to October 2019. This retrospective cohort study uses the Department of Defense Trauma Registry, Armed Services Blood Program database, and Military Trauma Mortality Review, while abstractors will use Theater Medical Data Store and Web Interface Patient Records to collect transfusion timing data. This study includes patients, who received blood products or died before receiving blood, treated at US military medical treatment facilities. The primary endpoints are survival at 6 hours, 24 hours, and 30 days postinjury. Secondary outcomes include infection, renal dysfunction, pulmonary dysfunction, and thromboembolic event. Exposure will be defined by blood product transfusion. Study groups will be frequency matched. Cox proportional hazards will compare patients who received warm fresh whole blood, low titer type-O whole blood, or only component therapy, while using adjustment for type of blood product transfused as a time-dependent covariate. Multilevel mixed-effects logistic regression will determine the effect of incompatible plasma in low titer type-O whole blood. An analysis plan for the Deployed HEROES study was developed with the aim of minimizing bias. This study will inform the optimal resuscitation strategies, which will potentially have a substantial impact on combat mortality. If whole blood is found to be the optimal transfusion strategy, this finding will be crucial in future operating environments involving dispersed medical assets. These results will provide critical information necessary for combat casualty care guidelines. Prognostic and epidemiological; Level III.