Luc J.M. Mortelmans

Patients' and relatives' view on witnessed resuscitation in the emergency department: a prospective study

Background The appropriateness of family witnessing resuscitation (FWR) is an ethical dilemma with most emergency care providers being opponents. We hypothesized that patients and their families prefer to witness resuscitation of their loved ones. Methods One hundred and fifty patients treated for potential life-threatening conditions in our emergency department were presented with a survey on FWR in the reconvalescence phase. They were asked to give their opinion supposing their situation had worsened, requiring a resuscitation effort. Their closest relatives were asked to complete a related questionnaire. Results Mean age was 67 years (patient group) and 55 years (relatives group). Fifty-eight percent of the patients were males with only 33% males in the relatives group. Seventy-two percent of the patients preferred the presence of a relative during resuscitation, although 35% estimate that this could be quite a traumatic experience. Forty-one percent had a history of serious medical problems. In the relatives group, 75% expressed their wish to stay with their loved ones and 49% did not fear that this would be too traumatic. There was a good match in patient and family attitude towards FWR (P<0.001). Relatives of a patient with a serious medical history were significantly more in favour of FWR (P<0.01). Conclusion Our study showed that patients and relatives preferred family presence in emergency department during resuscitation, even when the fear of traumatic effects is considered. It will be a great challenge training emergency care providers for this situation. Staff shortages might compromise the essential support of family members in such situations.

Differential diagnosis between viral and bacterial meningitis in children

Objective The differential diagnosis between viral meningitis and bacterial meningitis is often very difficult. The results of peripheral blood and spinal fluid analysis are not 100% accurate. We tried to find a useful ‘bedside’ decision-making tool, based on laboratory results readily available at the emergency department. Methods Retrospective study design. Analysis of a consecutive series of all children (age 0–15 years) admitted to the paediatric ward because of a viral or bacterial meningitis, in the period from 1997 to September 2005. Results Seventy-one children with viral and 21 with bacterial meningitis were included. Bacterial meningitis occurred at much younger ages than viral meningitis. The paediatrician decided to administer antibiotics in 41 of 71 children with viral meningitis and in all children with bacterial meningitis. We developed a ‘bacterial meningitis score’ based on C-reactive protein in peripheral blood, as well as glucose and protein in cerebrospinal fluid. Using this score, we could distinguish 54 of 71 patients with viral meningitis from the group with bacterial meningitis. When the dispensing of antibiotics was based on this score, only 16 patients with viral meningitis would receive antibiotics. Conclusion We present a bedside bacterial meningitis score. Using this bacterial meningitis score as a decision-making tool, we would be able to avoid antibiotics in a large number of children with viral meningitis. As this gives a 100% success rate, thus guaranteeing that bacterial meningitis patients would receive the proper therapy, our bacterial meningitis score could be an accurate decision-support tool.

Should relatives witness resuscitation in the emergency department? The point of view of the Belgian Emergency Department staff.

Objective To assess the opinion of Belgian Emergency Department (ED) staff regarding family-witnessed resuscitation (FWR). Methods All 142 Belgian EDs were sent a questionnaire on hospital-related data and personal questionnaires for the ED staff concerning their opinion on FWR. Opinions of physicians, nurses and other emergency care providers were compared and related with hospital or sociodemographic data. Results Eighty-five ED services (60%) responded with a total of 1143 personal questionnaires: of these 79% were nurses, and 19% physicians. Eighty percent of the hospitals had a prehospital intervention team. Only two departments (2.5%) practiced structured FWR; 21% put the relatives in the corridor. Eleven percent did not give any information at all to relatives. Fourteen percent organized ‘training in coping with relatives’. Forty-one percent of the staff members had been asked for FWR but only 33% were positive about it. Fifty-six percent thought that relatives could be of use in the shock room. Sixty-six percent experienced it as a burden. Sixty-five percent thought that FWR helps in grieving but 93% feared traumatic distress. Sixty-four percent would like to attend the resuscitation of their own relatives. Thirty-five percent fear a high risk of complaints. Prehospital experience, higher workload, seniority and male staff are significant advantages towards FWR. Emergency physicians are more positive towards FWR, nurses less so, followed by other physicians. Conclusion The Belgian ED staff is still unconvinced about FWR. Despite evidence-based data they still think that resuscitation is traumatizing for relatives. Experience, both in as well as out of hospital, is a positive factor.

Seizures and hyponatremia after excessive intake of diet coke.

We describe a case of epileptic seizures after a massive intake of diet coke. Apart from the hyponatremia due to water intoxication the convulsions can be potentiated by the high dose of caffeine and aspartame from the diet coke. To our knowledge this is the first report of seizures due to excessive diet coke intake.

Atlantoaxial rotatory subluxation.

Organophosphates are widely used as pesticides in agriculture. They can cause poisoning by accidental exposure or in suicide attempts. Organophosphates cause poisoning by inhibiting the acetyl cholinesterase at the cholinergic synapses [1]. Clinically, the diagnosis of organophosphate poisoning (OPP) is mainly based on the patient’s clinical findings, followed by laboratory tests. Sometimes the diagnosis can be difficult, as in our case, because it may mimic other clinical toxicity conditions. In the literature, the reports of conditions mimicking acute OPP are extremely rare. These include brainstem stroke [2,3], a foreign body aspiration [4], and food poisoning [5]. We did not, however, meet any case of OPP mimicking opioid intoxication in the literature. Contrary to previous reports, in our case, diagnosis was not made after recovery with atropine and/or oxime therapy, but with decreased cholinesterase activity.

Belgian senior medical students and disaster medicine, a real disaster?

Throughout history, medical students have been involved in patient care of large-scale mass casualty incidents. From the Spanish flu pandemic over devastating earthquakes to the 9/11 massacre, they have been deployed in victim care. The Belgian Royal Academy of Medicine even mentioned them as an important player in the national H5N1 pandemic plan in 2005. Despite this, we know from the literature that disaster medicine education is limited in medical curricula worldwide [1–4]. How can we rely on their help if they are not prepared? Our hypothesis is that, in Belgium, senior medical students have minimal preparation for disaster medicine in their curriculum.

Mass carbon monoxide poisoning at an ice-hockey game: initial approach and long-term follow-up

Objectives A mass carbon monoxide (CO) intoxication during an ice-hockey game is described. Two hundred and thirty-five patients were seen in different hospitals, 88 of them the same night at the nearby emergency department. To evaluate long-term implications and to identify relevant indicators, a follow-up study was organized 1 year after the incident. Methods Apart from the file data from the emergency departments, a 1-year follow-up mailing was sent to all patients. Results One hundred and ninety-one patients returned their questionnaire (86%). The mean age of the patients was 28 years, with 61% men. The mean carboxyhaemoglobin (COHb) was 9.9%. COHb levels were significantly higher for individuals on the ice (referee, players and maintenance personnel). There was a significant relationship with the initial presence of dizziness, fatigue and the COHb level. Headache, abdominal pain, nausea and vomiting were not significantly related to the COHb levels. The relationship between symptoms and CO level, however, should be interpreted with caution as there was a wide range between exposure and blood tests. 5.2% of patients had residual complaints, all including headache, with a significant higher incidence with high COHb levels. Only two patients had an abnormal neurological control (one slightly disturbed electroencephalography and one persistent encephalopathic complaint). Work incapacity was also significantly related to COHb levels. Conclusion CO mass poisonings remain a risk in indoor sporting events. Although it causes an acute mass casualty incident, it is limited in time and delayed problems are scarce. Symptomatology is a poor tool for triage. The best prevention is the use of nonmineral energy sources such as for example electricity.

Preparedness of Belgian civil hospitals for chemical, biological, radiation, and nuclear incidents: Are we there yet?

Objective As one of Europe’s most densely populated countries with multiple nuclear installations and a prominent petrochemical industry, Belgium is at some reasonable risk for terrorist attacks or accidental chemical, biological, radiation, and nuclear (CBRN) incidents. We hypothesize that local hospitals are not sufficiently prepared to deal with these incidents. Materials and methods All 138 Belgian hospitals with an emergency department (ED) were sent a survey on their preparedness. Data on hospital disaster planning, risk perception, availability of decontamination units, personal protective equipment, antidotes, radiation detection, infectiologists, isolation measures, and staff training were collected. Results The response rate was 72%. Although 71% of hospitals reported being at risk for CBRN incidents, only 53% planned for the same in their disaster plans. Only 11% of hospitals had decontamination facilities in front of or at the ED entrance and only 6% had appropriate personal protective equipment for triage and decontaminating teams. Atropine was available at all centers, but more specific antidotes such as hydroxycobolamine, thiosulphate, or pralidoxime were less available (47, 47, and 19%, respectively). Six percent of hospitals had radiodetection equipment with an alarm function and 14% had a nuclear specialist available 24/7. Infectiologists were continuously available in 26% of the total EDs surveyed. Individual isolation facilities were present in 36% of the EDs, and isolation facilities capable of housing larger groups were present in 9%. University hospitals were significantly better prepared than community hospitals. Conclusion There are serious gaps in hospital preparedness for CBRN incidents in Belgium. Lack of financial resources is a major obstacle in achieving sufficient preparedness.

Hospitals: Soft Target for Terrorism?

In recent years, the world has been rocked repeatedly by terrorist attacks. Arguably, the most remarkable were: the series of four coordinated suicide plane attacks on September 11, 2001 on buildings in New York, Virginia, and Pennsylvania, USA; and the recent series of two coordinated attacks in Brussels (Belgium), on March 22, 2016, involving two bombings at the departure hall of Brussels International Airport and a bombing at Maalbeek Metro Station located near the European Commission headquarters in the center of Brussels. This statement paper deals with different aspects of hospital policy and disaster response planning that interface with terrorism. Research shows that the availability of necessary equipment and facilities (eg, personal protective clothing, decontamination rooms, antidotes, and anti-viral drugs) in hospitals clearly is insufficient. Emergency teams are insufficiently prepared: adequate and repetitive training remain necessary. Unfortunately, there are many examples of health care workers and physicians or hospitals being targeted in both political or religious conflicts and wars. Many health workers were kidnapped and/or killed by insurgents of various ideology. Attacks on hospitals also could cause long-term effects: hospital units could be unavailable for a long time and replacing staff could take several months, further compounding hospital operations. Both physical and psychological (eg, posttraumatic stress disorder [PTSD]) after-effects of a terrorist attack can be detrimental to health care services. On the other hand, physicians and other hospital employees have shown to be involved in terrorism. As data show that some offenders had a previous history with the location of the terror incident, the possibility of hospitals or other health care services being targeted by insiders is discussed. The purpose of this report was to consider how past terrorist incidents can inform current hospital preparedness and disaster response planning. De Cauwer H , Somville F , Sabbe M , Mortelmans LJ . Hospitals: soft target for terrorism? Prehosp Disaster Med. 2017;32(1):94-100.

Are Belgian hospitals prepared for an H5N1-pandemic?

Objective Virulent airborne diseases can be a real burden to a nations health system. The most recent threat is the fear of a mutation-induced H5N1-influenza pandemic. We studied whether Belgian hospitals are able to deal with H5N1-influenza infected patients in the case of a pandemic. Many patients, including children, may require artificial ventilation within 48 h after admission. Methods A survey aimed at determining ‘availability and preparedness’ was sent by e-mail to the different Belgian Emergency Departments. Results and discussion Sixty-five hospitals were finally included. The amount of patients being potentially admitted is limited, owing to the reduced number of intensive care beds equipped with automatic ventilators. Furthermore, the number of available intensive care beds for children is still lower than for adult patients. The number of mortuary places, in the case of a catastrophe, is also insufficient. Although most hospitals set up a disaster plan on H5N1, there are only limited stocks of antiviral medication to protect the hospital staff in the acute phase. A separate triage area is only available in a limited number of hospitals. We conclude that Belgian hospitals and emergency departments are not equipped to deal with potential pandemic situations.