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The medical response to terrorist attacks does not just involve saving lives, but it also serves as a message to our people: we shall never surrender to terrorism. In this Viewpoint, we present a synopsis of the measures taken in France to improve our medical capacity to face the unexpected (table).8

The aim of this proof-of-concept study was to evaluate if trained dogs could discriminate between sweat samples from symptomatic COVID-19 positive individuals (SARS-CoV-2 PCR positive) and those from asymptomatic COVID-19 negative individuals. The study was conducted at 2 sites (Paris, France, and Beirut, Lebanon), followed the same training and testing protocols, and involved six detection dogs (three explosive detection dogs, one search and rescue dog, and two colon cancer detection dogs). A total of 177 individuals were recruited for the study (95 symptomatic COVID-19 positive and 82 asymptomatic COVID-19 negative individuals) from five hospitals, and one underarm sweat sample per individual was collected. The dog training sessions lasted between one and three weeks. Once trained, the dog had to mark the COVID-19 positive sample randomly placed behind one of three or four olfactory cones (the other cones contained at least one COVID-19 negative sample and between zero and two mocks). During the testing session, a COVID-19 positive sample could be used up to a maximum of three times for one dog. The dog and its handler were both blinded to the COVID-positive sample location. The success rate per dog (i.e., the number of correct indications divided by the number of trials) ranged from 76% to 100%. The lower bound of the 95% confidence interval of the estimated success rate was most of the time higher than the success rate obtained by chance after removing the number of mocks from calculations. These results provide some evidence that detection dogs may be able to discriminate between sweat samples from symptomatic COVID-19 individuals and those from asymptomatic COVID-19 negative individuals. However, due to the limitations of this proof-of-concept study (including using some COVID-19 samples more than once and potential confounding biases), these results must be confirmed in validation studies.

Purpose The majority of terrorist acts are carried out by explosion or shooting. The objective of this study was first, to describe the management implemented to treat a large number of casualties and their flow together with the injuries observed, and second, to compare these resources according to the mechanism of trauma. Methods This retrospective cohort study collected medical data from all casualties of the attacks on November 13th 2015 in Paris, France, with physical injuries, who arrived alive at any hospital within the first 24 h after the events. Casualties were divided into two groups: explosion injuries and gunshot wounds. Results 337 casualties were admitted to hospital, 286 (85%) from gunshot wounds and 51 (15%) from explosions. Gunshot casualties had more severe injuries and required more in-hospital resources than explosion casualties. Emergency surgery was required in 181 (54%) casualties and was more frequent for gunshot wounds than explosion injuries (57% vs. 35%, p  < 0·01). The types of main surgery needed and their delay following hospital admission were as follows: orthopedic [ n  = 107 (57%); median 744 min]; general [ n  = 27 (15%); 90 min]; vascular [ n  = 19 (10%); median 53 min]; thoracic [ n  = 19 (10%); 646 min]; and neurosurgery [n = 4 (2%); 198 min]. Conclusion The resources required to deal with a terrorist attack vary according to the mechanism of trauma. Our study provides a template to estimate the proportion of various types of surgical resources needed overall, as well as their time frame in a terrorist multisite and multitype attack. Funding Assistance Publique–Hôpitaux de Paris.

There is an increasing need for rapid, reliable, non-invasive, and inexpensive mass testing methods as the global COVID-19 pandemic continues. Detection dogs could be a possible solution to identify individuals infected with SARS-CoV-2. Previous studies have shown that dogs can detect SARS-CoV-2 on sweat samples. This study aims to establish the dogs’ sensitivity (true positive rate) which measures the proportion of people with COVID-19 that are correctly identified, and specificity (true negative rate) which measures the proportion of people without COVID-19 that are correctly identified. Seven search and rescue dogs were tested using a total of 218 axillary sweat samples (62 positive and 156 negative) in olfaction cones following a randomised and double-blind protocol. Sensitivity ranged from 87% to 94%, and specificity ranged from 78% to 92%, with four dogs over 90%. These results were used to calculate the positive predictive value and negative predictive value for each dog for different infection probabilities (how likely it is for an individual to be SARS-CoV-2 positive), ranging from 10–50%. These results were compared with a reference diagnostic tool which has 95% specificity and sensitivity. Negative predictive values for six dogs ranged from ≥98% at 10% infection probability to ≥88% at 50% infection probability compared with the reference tool which ranged from 99% to 95%. Positive predictive values ranged from ≥40% at 10% infection probability to ≥80% at 50% infection probability compared with the reference tool which ranged from 68% to 95%. This study confirms previous results, suggesting that dogs could play an important role in mass-testing situations. Future challenges include optimal training methods and standardisation for large numbers of detection dogs and infrastructure supporting their deployment.

In the prehospital setting, early identification of septic shock (SS) with high risk of mortality aims to initiate early treatments and to decide delivery unit (emergency department (ED) or intensive care unit (ICU)). In this context, there is a need for a prognostic measure of severity and death in order to early detect patients with a higher risk of pejorative evolution. In this study, we describe the association between prehospital shock index (SI) and mortality at day 28 of patients with SS initially cared for in the prehospital setting by a mobile intensive care unit (MICU). Patients with SS cared for by a MICU between January 2016 and May 2019 were retrospectively analyzed. Using propensity score, the association between SI and mortality was assessed by Odd Ratio (OR) with 95 percent confidence interval [95 CI]. One-hundred and fourteen patients among which 78 males (68%) were analysed. The mean age was 71 ± 14 years old. SS was mainly associated with pulmonary (55%), digestive (20%) or urinary (11%) infection. Overall mortality reached 33% (n = 38) at day 28. Median SI [interquartile range] differed between alive and deceased patients: 0.73 [0.61–1.00] vs 0.80 [0.66–1.10], p < 0.001*). After adjusting for confounding factors, the OR of SI > 0.9 was 1.17 [1.03–1.32]. In this study, we report an association between prehospital SI and mortality of patients with prehospital SS. A SI > 0.9 is a readily available tool correlated with increased mortality of patients with SS initially cared for in the prehospital setting.

Guidelines on sepsis management recommend early recognition, diagnosis and treatment, especially early antibiotic therapy (ABT) administration in order to reduce septic shock (SS) mortality. However, the adequacy of probabilistic prehospital ABT remains unknown. From May 2016 to March 2021, all consecutive patients with SS cared for by a prehospital mICU intervention were retrospectively analyzed. Among 386 patients retrospectively analyzed, 119 (33%) received probabilistic prehospital ABT, among which 74% received a 3rd generation cephalosporin: 31% cefotaxime and 42% ceftriaxone. No patient had a serious adverse effect related to ABT administration. Overall mortality rate on day-30 was 29%. Among the 119 patients with prehospital ABT, bacteriological identification was obtained for 81 (68%) patients with adequate prehospital ABT for 65 patients (80%) of which 10 (15%) deceased on day-30. Conversely, among the 16 (20%) patients with inadequate prehospital ABT, 9 patients (56%) were deceased on day-30. Prehospital adequate ABT was significantly different between alive and deceased patients on day-30 (p = 4.10−3). After propensity score matching, a significant association between adequate prehospital ABT administration and day-30 mortality was observed (aOR = 0.09 [0.01–0.47]). Inverse probability treatment weighting with multivariable logistic regression reported a day-30 mortality decrease in the adequate prehospital ABT group: aOR = 0.70 [0.53–0.93]. Among SS cared for by a mICU, probabilistic prehospital ABT is adequate most of the time and associated with a day-30 mortality decrease. Further prospective studies are needed to confirm these results and the weight of prehospital ABT in the prehospital bundle of care for SS.

Precise cerebral dynamics of action of the anesthetics are a challenge for neuroscientists. This explains why there is no gold standard for monitoring the Depth of Anesthesia (DoA) and why experimental studies may use several electroencephalogram (EEG) channels, ranging from 2 to 128 EEG-channels. Our study aimed at finding the scalp area providing valuable information about brain activity under general anesthesia (GA) to select the more optimal EEG channel to characterized the DoA. We included 30 patients undergoing elective, minor surgery under GA and used a 32-channel EEG to record their electrical brain activity. In addition, we recorded their physiological parameters and the BIS monitor. Each individual EEG channel data were processed to test their ability to differentiate awake from asleep states. Due to strict quality criteria adopted for the EEG data and the difficulties of the real-life setting of the study, only 8 patients recordings were taken into consideration in the final analysis. Using 2 classification algorithms, we identified the optimal channels to discriminate between asleep and awake states: the frontal and temporal F8 and T7 were retrieved as being the two bests channels to monitor DoA. Then, using only data from the F8 channel, we tried to minimize the number of features required to discriminate between the awake and asleep state. The best algorithm turned out to be the Gaussian Naïve Bayes (GNB) requiring only 5 features (Area Under the ROC Curve - AUC- of 0.93 +/- 0.04). This finding may pave the way to improve the assessment of DoA by combining one EEG channel recordings with a multimodal physiological monitoring of the brain state under GA. Further work is needed to see if these results may be valid to asses the depth of sedation in ICU.

A 61-year-old man with spinal cord compression underwent therapeutic laminectomy of the fifth vertebra and laminectomy and vertebroplasty of the fourth vertebra. During the vertebroplasty, polymethylmethacrylate cement leaked into the paravertebral vascular system. A 61-year-old man with spinal cord compression caused by a vertebral hemangioma underwent therapeutic laminectomy of the fifth vertebra and laminectomy and vertebroplasty of the fourth vertebra. During the vertebroplasty, polymethylmethacrylate cement leaked into the paravertebral vascular system. In the recovery room, the patient was mildly hypoxemic but otherwise asymptomatic. A chest radiograph and an image subsequently obtained with computed tomography revealed that some of the injected cement had embolized and entered the systemic circulation, where it lodged in the segmental and subsegmental pulmonary arteries of the middle lobes and the superior segment of the lower lobe (arrows) of the . . .

Another columnist, who is also an emergency physician of Paris SAMU, was still at a meeting with firefighters and emergency medical services leaders to discuss how to improve hospital admission services about 600 meters away when his mobile phone rang. Growing evidence from the military experience points out the meaning of both early external hemostasis and surgical intervention among severely injured patients with exsanguinating hemorrhage, meaning in prehospital setting rapid transport to operating room of trauma center after in-the-field management of immediately life-threatening injuries.

We report the case of a 57-year-old woman found at home who received an ECG after having recovered from a seizure, without any clinical cardiac anomaly. The ECG revealed an elevation of the ST segment from the V1 to V5 leads and negative T waves from V1 to V5 leads. At her hospital admission, the emergency care unit (ECU) nurse performed another ECG. It no longer showed any repolarisation anomaly. However, the ECU nurse had put the precordial electrodes 3 cm too low, probably due to the patient’s voluminous breasts. In the end, the pathological trace reappeared after we returned the electrodes to their initial positions. Malpositioning of the electrodes caused a seemingly normal ECG result with life-threatening consequences.