Fabrice Dami

Acute stroke chameleons in a university hospital: Risk factors, circumstances, and outcomes

Objective: To identify risk factors, circumstances, and outcomes for individuals with acute ischemic stroke (AIS) chameleons (AIS-C) arriving in the emergency department of a university hospital. Methods: We retrospectively reviewed all patients with AIS from the prospectively constructed Acute Stroke Registry and Analysis of Lausanne during 8.25 years. AIS-C were defined as a failure to suspect stroke or as incorrect exclusion of stroke diagnosis. They were compared with patients diagnosed correctly at the time of admission. Results: Forty-seven of 2,200 AIS were missed (2.1%). These AIS-C were either very mild or very severe strokes. Multivariate analysis showed a younger age in patients with AIS-C (odds ratio [OR] per year 0.98, p < 0.01), less prestroke statin treatment (OR 0.29, p = 0.04), and lower diastolic admission blood pressure (OR 0.98 p = 0.04). They showed less eye deviation (OR 0.21, p = 0.04) and more cerebellar strokes (OR 3.78, p < 0.01). AIS-C were misdiagnosed as other neurologic (42.6% of cases) or nonneurologic (17.0%) disease, as unexplained decreased level of consciousness (21.3%), and as concomitantly present disease (19.1%). At 12 months, patients with AIS-C had less favorable outcomes (adjusted OR 0.21, p < 0.01) and higher mortality (adjusted OR 4.37, p < 0.01). Conclusions: AIS are missed in patients with younger age with a lower cerebrovascular risk profile and may be masked by other acute conditions. Patients with chameleons present more often with milder strokes or coma, fewer focal signs and cerebellar strokes, and have higher disability and mortality rates at 12 months. These findings may be used to raise awareness in emergency departments to recognize and treat such patients appropriately.

Coordination of Emergency Medical Services for a Major Road Traffic Accident on a Swiss Suburban Highway

On 9th April 2008 at 2:14 p.m., on the highway between Lausanne and Vevey in western Switzerland, there was a 72-car pileup including five trucks that caused one death and injured 26 others. The relatively light toll was attributed to reduced vehicular speeds on account of foggy weather, together with the quick actions and effectiveness of the first responders and the excellent collaboration between the various rescue groups (medical rescue services, fire and police departments). For the first time, we used an innovative on-site medical command and control system, based on a binomial team. Two hours after the accident, the last of the injured had been evacuated and first aid on the site had ended. This article describes how the Emergency Medical Services from the State of Vaud, Switzerland, handled the situation and how the binomial team is structured.

Palliative Care and Prehospital Emergency Medicine: Analysis of a Case Series

Abstract Palliative care, which is intended to keep patients at home as long as possible, is increasingly proposed for patients who live at home, with their family, or in retirement homes. Although their condition is expected to have a lethal evolution, the patients—or more often their families or entourages—are sometimes confronted with sudden situations of respiratory distress, convulsions, hemorrhage, coma, anxiety, or pain. Prehospital emergency services are therefore often confronted with palliative care situations, situations in which medical teams are not skilled and therefore frequently feel awkward. We conducted a retrospective study about cases of palliative care situations that were managed by prehospital emergency physicians (EPs) over a period of 8 months in 2012, in the urban region of Lausanne in the State of Vaud, Switzerland. The prehospital EPs managed 1586 prehospital emergencies during the study period. We report 4 situations of respiratory distress or neurological disorders in advanced cancer patients, highlighting end-of-life and palliative care situations that may be encountered by prehospital emergency services. The similarity of the cases, the reasons leading to the involvement of prehospital EPs, and the ethical dilemma illustrated by these situations are discussed. These situations highlight the need for more formal education in palliative care for EPs and prehospital emergency teams, and the need to fully communicate the planning and implementation of palliative care with patients and patients’ family members.

Use of lights and siren: is there room for improvement?

Objective The objective of this study was to analyse the use of lights and siren (L&S) during transport to the hospital by the prehospital severity status of the patient and the time saved by the time of day of the mission. Methods We searched the Public Health Services data of a Swiss state from 1 January 2010 to 31 December 2010. All primary patient transports within the state were included (24 718). The data collected were on the use of L&S, patient demographics, the time and duration of transport, the type of mission (trauma vs. nontrauma) and the severity of the condition according to the National Advisory Committee for Aeronautics (NACA) score assigned by the paramedics and/or emergency physician. We excluded 212 transports because of missing data. Results A total of 24 506 ambulance transports met the inclusion criteria. L&S were used 4066 times, or in 16.6% of all missions. Of these, 40% were graded NACA less than 4. Overall, the mean total transport time to return to the hospital was 11.09 min (confidence interval 10.84–11.34) with L&S and 12.84 min (confidence interval 12.72–12.96) without. The difference was 1.75 min (105 s; P<0.001). For night-time runs alone, the mean time saved using L&S was 0.17 min (10.2 s; P=0.27). Conclusion At present, the use of L&S seems questionable given the severity status or NACA score of transported patients. Our results should prompt the implementation of more specific regulations for L&S use during transport to the hospital, taking into consideration certain physiological criteria of the victim as well as time of day of transport.

Proposition and operational characteristics of a new dispatch scale to specifically identify acute strokes.

Objective Prehospital recognition of an acute stroke improves the time from onset to thrombolysis and rates of reperfusion therapy. Studies conducted to evaluate paramedic and dispatcher performance in suspecting stroke are disappointing. This study addresses the specific issue of stroke recognition by dispatchers, taking into account delay in reporting the onset of symptoms (<5 h). Methods This is an observational analysis conducted over a 12-month period. Dispatchers used a modified Cincinnati Stroke Scale to specifically identify acute strokes in a criteria-based dispatch. Data were extracted from the State’s dispatch and the State’s stroke centre. All calls to the dispatch were included. Dispatcher’s suspicion of acute stroke and the patient’s final destination and diagnosis were collected. Simple descriptive statistics were used. Sensitivity and positive predictive value were calculated. Results The dispatch received 27 719 calls resulting in ambulance dispatches; 427 calls [1.5%; 95% confidence interval (CI) 1.4–1.7] were classified as suspicion of acute stroke by dispatchers, and 40 of them (9.4%; 95% CI 6.6–12.1) fulfilled the criteria for thrombolysis (sensitivity 67.8%; 95% CI 54.3–79.4%). Dispatchers missed 19 of 59 strokes (32.2%; 95% CI 20.3–44.1) that received thrombolysis; 16 cases were missed because of unspecific acute symptoms (unconsciousness, dyspnoea), and three more because of unspecific nonacute symptoms (vertigo, dizziness). Conclusion The revised Cincinnati Stroke Scale for dispatch adds the notion of delay in the process of triage. It identifies 67.8% and misses 32.2% of the stroke patients treated by thrombolysis. Its performance is similar to previous results using the regular Cincinnati Stroke Scale, but allows for targeting acute strokes.

Dispatch centres: what is the right population catchment size?

Literature on medical dispatch is growing, focusing mainly on efficiency (under and overtriage) and dispatch-assisted CPR. But the issue of population catchment size, functional costs and rationalization is rarely addressed. If we can observe a trend toward a decreasing number of dispatch centres in many European countries, there is today no evidence on what is the right catchment size to reach the best balance between quality of services and costs.

University Hospital Struck Deaf and Silent by Lightning: Lessons to Learn.

We describe how an electromagnetic wave after a lightning strike affected a university hospital, including the communication shutdown that followed, the way it was handled, and the lessons learned from this incident.

Hospital disaster preparedness in Switzerland

STUDY OBJECTIVE Hospital preparedness is an essential component of any developed health care system. However, there is no national legislation in Switzerland. The objective of this inquiry was to establish the geographic distribution, availability and characteristics of hospital preparedness across Switzerland. METHODS A questionnaire regarding hospital preparedness in 2006 was addressed to all heads responsible for emergency departments (ED). The survey was initiated in 2007 and finalised in 2012. RESULTS Of the 138 ED, 122 (88%) returned the survey. Eighty nine EDs (82%) had a disaster plan. CONCLUSIONS Our study identified an insufficient rate of hospitals in which emergency physicians reported a disaster plan. The lack of national or cantonal legislation regulating disaster preparedness may be partially responsible for this.

Mass Casualty Triage in the Case of Carbon Monoxide Poisoning: Lessons Learned

ABSTRACTCarbon monoxide (CO) can cause mass intoxication, but no standard triage algorithm specifically addresses CO poisoning. The roles of some recent diagnostic tools in triage as well as treatment with hyperbaric oxygen are controversial. We describe a mass casualty case of CO poisoning involving 77 patients, with a focus on the triage and treatment options decided on-site. The reasons for choosing these options are reviewed, and the pitfalls that occurred and the lessons learned from this major incident are described. We discuss the potential to improve the management of such an event and strategies to accomplish this, including simplifying triage and administering oxygen to all exposed persons for 6 h. (Disaster Med Public Health Preparedness. 2018; 12: 373-378).

Prehospital Emergency Medical Services Departure Interval: Does Patient Age Matter?

Introduction The concept of response time with minimal interval is intimately related to the practice of emergency medicine. The factors influencing this time interval are poorly understood. Problem In a process of improvement of response time, the impact of the patients age on ambulance departure intervals was investigated. METHOD This was a 3-year observational study. Departure intervals of ambulances, according to age of patients, were analyzed and a multivariate analysis, according to time of day and suspected medical problem, was performed. RESULTS A total of 44,113 missions were included, 2,417 (5.5%) in the pediatric group. Mean departure delay for the adult group was 152.9 seconds, whereas it was 149.3 seconds for the pediatric group (P =.018). CONCLUSION A statistically significant departure interval difference between missions for children and adults was found. The difference, however, probably was not significant from a clinical point of view (four seconds). Schnegg B , Pasquier M , Carron PN , Yersin B , Dami F . Prehospital Emergency Medical Services departure interval: does patient age matter? Prehosp Disaster Med. 2016;31(6):608-613.