Jean-Louis Caillot

The epidemiology of trauma of the genitourinary system after traffic accidents: analysis of a register of over 43,000 victims

To analyse the frequency and type of injury to the genitourinary system, by user category, after traffic accidents.

Suicide with “non-lethal” firearm

patient was immediately transferred to the operating room. During induction of anaesthesia, she had a cardiac arrest. Sternotomy was done and blood evacuated from the pericardium. The left ventricular wall had a 6 3 cm bruised and bleeding surface, and there was a 3 mm wound that squirted blood near the apex. There were no bullets in the pericardium, and it had not been perforated. The left pleural cavity was opened and 3 L of blood drained. There was a large laceration of the lingula that poured out blood and air. 11 brown rubber bullets were removed from the left pleural cavity. Bleeding from the heart was nearly controlled, but the bruised area of the left ventricle burst, and attempts at repair were unsuccessful. The patient died on the table. Necropsy showed a contact entrance wound of 35 28 mm, with an abrased ring 3 mm wide; a subcutaneous blast chamber 7 cm diameter and a haematoma of the left breast and pectoral muscle. There were fractures of anterior arch of the third and fourth ribs and perforation of the second and the third left intercostal space. The 12th rubber bullet was found in the pleural cavity. The weapon used for this suicide was a “non-lethal” single-barrelled hand gun, type GC27, manufactured by SAPL (France) and loaded with a “non-lethal” 12 gauge, 50 mm mini Gomm-Cogne cartridge that contains 12 rubber bullets of 7 mm diameter (figure). “Non-lethal” weapons were first supplied to security forces. Deaths have been reported with rubber missiles (15 3·8 cm, 150 g) and with M-16 plastic and rubber ammunition. With rubber ammunition produced to be used in shotguns, severe but not lethal wounds have been reported. This is, to our knowledge, the first case of death due to such a weapon at contact range. The ventricular lesions are explained by the transmission of the kinetic energy of the missiles through the intact pericardium. Since these weapons are sold to be used by inexperienced citizens for self-defence, reported further lethal accidents will probably occur.

Anticipated Detection of Imminent Surgeon–Patient Barrier Breaches. A Prospective Randomized Controlled Trial Using an Indicator Underglove System

The double gloving indicator underglove system (IUS) is based on a colored detection of the outer glove perforation. Our objective was to determine the IUS efficiency to detect outer glove perforations and to reduce the risks of blood and body fluids exposure, warning the surgeon before the breach of the surgeon–patient barrier (SPB). A series of 100 visceral surgical procedures were randomly assigned to either double (IUS) or single gloving. The noticed glove perforations (using the water test method) and the IUS efficiency were analyzed in 99 procedures. In 49 single-gloving procedures, 19 perforations were noticed: one was immediately perceived (perceived accidental exposure, PAE); 3 were discovered as the gloves were being removed, and 15 were undetected before the water test (unperceived prolonged contact, UPC). In 50 double-gloving procedures (IUS), 16 perforations were noticed, all of them involving only the outer glove: the IUS allowed immediate detection of 3 perforations without any blood exposure; 13 other perforations went undetected but without any UPC. In conjunction with the protective quality of double gloving, the IUS allows detection of significant breaches of the outer glove before the breach of the SPB.

Ballistic study of the SAPL GC27 gun: Is it really nonlethal?

To evaluate the potential dangers of the “nonlethal” 12-gauge single-shot handgun SAPL GC27 with Fun-Tir (FT) and mini-Gomm-Cogne (mGC) ammunition, a ballistic study was performed with both types of ammunition. Nine unembalmed human corpses covered with a cloth sheet were shot through the right and left pectoral regions. With the mGC ammunition, rib fractures were observed when the firing range was less than 2 meters, skin perforation when the range was less than 1.5 meters, with lung injuries at less than 0.2 meter; the heart and the aorta were lacerated at contact range (0 meter). No skin perforation was observed with the FT ammunition, but rib fractures were observed when it was fired at up to 2 meters. Our study shows that the mGC ammunition, shot by the CG27 firearm, can be lethal at contact range and that pellets penetrate the skin at ranges of less than 1 meter. These results led us to conclude that this weapon is too dangerous to be marketed as a “nonlethal” weapon. The term “reduced wounding power weapon” is preferable.

Fixed-Distance Model for Balloon Placement During Fluoroscopy-Free Resuscitative Endovascular Balloon Occlusion of the Aorta in a Civilian Population

Importance Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an innovative procedure in the treatment of noncompressible truncal hemorrhage. However, readily available fluoroscopy remains a limiting factor in its widespread implementation. Several methods have been proposed to perform REBOA without fluoroscopic guidance, and these methods were adapted predominantly from the military theater. Objective To develop a method for performing REBOA in a civilian population using a standardized distance from a set point of entry. Design, Setting, and Participants A retrospective study of whole-body computed tomographic (CT) scans from a cohort of 280 consecutive civilian trauma patients from University Hospitals of Lyon, France, was used to calculate the endovascular distances from both femoral arteries at the level of the upper border of the symphysis pubis to aortic zone I (descending thoracic aorta) and zone III (infrarenal aorta). These whole-body CT scans were performed between 2013 and 2015. Data were analyzed from July 16 to December 7, 2015. Main Outcomes and Measures Two segments (1 per zone) common to all CT scans were isolated, and their location, length, prevalence in the cohort, and predicted prevalence in the general population were calculated by inverting 99% certainty tolerance limits. Results Among the 280 trauma patients (140 men and 140 women) in this study, the mean (SD) height was 170.7 (8.7) cm, and the mean (SD) age was 38.8 (16.5) years. The common segment in zone I (414-474 mm) existed in all CT scans. The common segment in zone III (236-256 mm) existed in 99.6% and 97.9% of CT scans from the right and left femoral arteries, respectively. These segments are expected to exist in 98.7% (zone I) and 94.9% (zone III) of the general population. Conclusions and Relevance Target distances for blind placement of REBOA exist with more than 94% prevalence in a civilian population. These findings support the expanded use of REBOA in emergency department and prehospital settings. Validation for safety and efficacy on cadaveric and clinical models is necessary.

Inadvertent prolonged fluid contact: an unappreciated professional risk for surgeons.

Sir, To avoid any blood or body ̄uid contact between a surgeon and his patient, surgical gloves and gowns have to constitute an unbroken sterile barrier. In operating room, the surgeon usually experiences needle-stick injury as a painful incident and instantaneously recognizes glove puncture: percutaneous blood exposure is authenticated but remains very brief. However, such a surgeon rarely spontaneously detects glove porosity, insensible glove micro puncture, or wet gown: these imperceptible incidents involve prolonged blood or body ̄uid cutaneous contact through unnoticed breaches in the surgeonpatient barrier. The integrity of this barrier can be well monitored using an electronic apparatus able to detect any abnormal ̄uid contact and to raise the alarm [1]. A prospective controlled study was performed during 80 randomly assigned to double or single gloving surgical procedures. Electronic detector (ElperÒ, Sofracob SA, Vienne, France) monitored surgeons during 238 hours and recorded 164 alarms. The surgeons only noticed 6 glove punctures, although 31 were electronically detected and con®rmed by postoperative glove examination. More signi®cantly, whereas the electronic device detected 57 ̄uid contacts authenticated as glove porosity and 76 ̄uid contacts authenticated as wet gown, surgeons never perceived any of them. Out of 164 detected barrier breakdowns, only 6 (3.6%) were spontaneously noticed by the surgeons [2]. In the absence of an electronic detector, the duration of inadvertent ̄uid contact that would have occurred from the time of the alarm to the end of the surgical procedure appears to be considerable. For 100 hours of operating time, a surgeon using single gloving would be in inadvertent ̄uid contact for 53 hours, but for only 29 hours when using double gloving (relative risk = 1.8, 95%CI: 1.3±2.5). The risk of viral transmission after prolonged cutaneous contaminating ̄uid contact is currently recognized [3]. Even so attempts to transmit bacteriophage through porous gloves had failed [4] and implied that the risk was minimal, unnoticed wet gowns and glove failures (including glove porosity) that involve channels large enough to permit the passage of many viruses [5] lead to potential viral contamination. The recent case of a professionally HIV contaminated surgeon who later transmitted HIV to a patient shows the disturbing reality of a two-way viral transmission through breaches in the aseptic barrier [6]. Surgical procedures should only be performed with double gloving, and companies should provide truly impermeable sterile single-use gowns. Currently, systematic electronic detection remains the only reliable method to alarm surgeons about inadvertent exposure to potentially contaminated body ̄uids.