•Early STRATEVAC is a French military specificity. This political choice ensures that wounded French soldiers are repatriated to France 24 hours after their injury.•The French military health service easily deploys an anesthesiologist/intensive care physician to provide medical care during the flight, accepting the risk of overtriage.•The majority of severe patients evacuated from the Sahel do not require intensive care during the flight.•Greater use of emergency physicians, especially for transporting stabilized patients, would provide more personnel trained in long-distance air transport.

Introduction The aim of this work was to introduce the new French forward resuscitation and surgical unit. It's also to discuss the choices and waivers granted to fit the tactical context of modern conflicts and the current epidemiology of combat casualties. Materials and Methods A multidisciplinary task force of 11 people proceeded to the conception and the creation of a new military resuscitation and surgical unit. The preliminary work included a scoping review of the combat casualties' epidemiology in modern conflicts and an analysis of the recent French medical-surgical treatment facilities lessons learned. In April 2019, a technical-operational evaluation was conducted to confirm all the technical, ergonomic, and organizational choices made during the design phase. Results The multidisciplinary task force resulted in the creation of the Damage Control Resuscitation and Surgical Team (DCRST). The DCRST focused on the resuscitation strategy, including transfusion of blood products, and the life-saving surgical procedures to be performed as close as possible to the point of injury. It was designed for the resuscitation of two patients: the life-saving surgery of two patients and the very short-term intensive care (<12 hours) of four patients at the same time. The DCRST provided sufficient autonomy to provide take care of four T1 and four T2 or T3 casualties per day for 48 hours. It was armed with 23 soldiers. The technical equipment represented 5,300 kg and 27 m(3). All the technical medical equipment could be stored in two 20-foot containers. Conclusion The DCRST represents a new paradigm in medical support of French military operations. It offers the advantage of two combat casualties' surgical management at the same time, as close as possible to the combat zone. It responds to a 2-fold epidemiological and logistical challenge.

Medical advice to the command is an essential activity though one little known to the forces’ medical service. It relies upon a relationship of confidence between doctor and commander and draws on experience, mutual respect and knowledge of each other’s specialisation—all of which require consolidation in order to improve effectiveness.

Le conseil médical au commandement est une activité essentielle, mais méconnue du Service de santé des Armées. Reposant sur une relation de confiance entre médecin et commandement, il s’appuie sur l’expérience, le compagnonnage et une connaissance mutuelle qu’il convient de consolider pour gagner en efficacité.

'We are at war', French President Emmanuel Macron said in an address to the nation on 16 March 2020. As part of this national effort, the French Military Medical Service (FMMS) is committed to the fight against COVID-19. This original report aimed to describe and detail actions that the FMMS has carried out in the nationwide fight against the COVID-19 pandemic in France, as well as overseas. Experts in the field reported major actions conducted by the FMMS during the COVID-19 pandemic in France. In just few weeks, the FMMS developed ad hoc medical capabilities to support national health authorities. It additionally developed adaptive, collective en route care via aeromedical and naval units and deployed a military intensive care field hospital. A COVID-19 crisis cell coordinated the French Armed Forces health management. The French Military Centre for Epidemiology and Public Health provided all information needed to guide the decision-making process. Medical centres of the French Armed Forces organised the primary care for military patients, with the widespread use of telemedicine. The Paris Fire Brigade and the Marseille Navy Fire Battalion emergency departments ensured prehospital management of patients with COVID-19. The eight French military training hospitals cooperated with civilian regional health agencies. The French military medical supply chain supported all military medical treatment facilities in France as well as overseas, coping with a growing shortage of medical equipment. The French Armed Forces Biomedical Research Institute performed diagnostics, engaged in multiple research projects, updated the review of the scientific literature on COVID-19 daily and provided expert recommendations on biosafety. Finally, even students of the French military medical academy volunteered to participate in the fight against the COVID-19 pandemic. In conclusion, in an unprecedented medical crisis, the FMMS engaged multiple innovative and adaptive actions, which are still ongoing, in the fight against COVID-19. The collaboration between military and civilian healthcare systems reinforced the shared objective to achieve the goal of 'saving the greatest number'.

BACKGROUND According to the Joint Theater Trauma Registry, 26% to 33% of war casualties develop acute respiratory distress syndrome (ARDS), with high mortality. Here, we aimed to describe ARDS incidence and severity among patients evacuated from war zones and admitted to French intensive care units (ICUs). METHODS We performed an observational retrospective multicentric review of all patients evacuated from war zones and admitted to French ICUs between 2003 and 2018. Our analysis included all medical and trauma patients developing ARDS according to the Berlin definition. We evaluated ARDS incidence, and determined ARDS severity from arterial blood gas analysis. Analyzed parameters included invasive ventilation duration, ARDS treatments, ICU stay length, and 30-day and 90-day mortalities. RESULTS Among 141 included patients (84% military; median age, 30 years), 57 (42%) developed ARDS. Acute respiratory distress syndrome was mild in 13 (22%) patients, moderate in 24 (42%) patients, and severe in 20 (36%) patients. Evacuation occurred in less than 26 hours for 32 war casualties, 17 non–war-related trauma patients, and 8 medical patients. Among severe trauma patients, median Injury Severity Score was 34, and Abbreviated Injury Scale thorax was 3. Upon French ICU admission, median partial pressure of oxygen in arterial blood/inspirated fraction of oxygen ratio was 241 [144–296]. Administered ARDS treatments included intubation (98%, n = 56), protective ventilation (87%, n = 49), neuromuscular blockade (76%, n = 43), prone position (16%, n = 9), inhaled nitric oxide (10%, n = 6), almitrine (7%, n = 7), and extracorporeal life support (4%, n = 2). Median duration of invasive ventilation was 13 days, ICU stay was 18 days, 30-day mortality was 14%, and 90-day mortality was 21%. CONCLUSION Acute respiratory distress syndrome was frequent and severe among French patients evacuated from war theaters. Improved treatment capacities are needed in the forward environment—for example, a specialized US team can provide extracorporeal life support for highly hypoxemic war casualties. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.

Introduction The doctrine of medical support during French military operations is based on a triptych: forward medical stabilization, forward damage control surgery, and early strategic aeromedical evacuation (Strategic-AE). The aim of this study was to describe the last piece, the evacuation process of the French Strategic-AE. Methods We conducted a retrospective cohort analysis using patient records from 2015 to 2017. All French service members requiring an air evacuation from a foreign country to a homeland medical facility were included. Data collected included age, medical diagnosis, priority categorization, boarding location, distance from Paris, type of plane and flight, medical team composition, timeline, and dispatch at arrival. Results We analyzed 2,129 patients evacuated from 71 countries, most from Africa (1,256), the Middle East (382), and South America (175). Most patients (1,958) were not severely injured, although some considered priority (103) or urgent (68). Diagnoses included disease (48.6%), nonbattle injuries (43%), battle stress (5.3%), and battle injuries (3%). 246 Strategic-AE used medical teams in flight, 136 of them in a dedicated Falcon aircraft. The main etiologies for those evacuations were battle injuries (24%), cardiovascular (15.4%), infections (8%), and neurologic (7.3%). The median time of management for urgent patients was about 16 hours but longer for priority patients (26 hours). Once in France, 1,146 patients were admitted to a surgery department and 96 to an intensive care unit. Conclusion This is the first study to analyze the French Strategic-AE system, which is doctrinally unique when compared to its North Atlantic Treaty Organization allies. North Atlantic Treaty Organization allies favor care in the theatre in place of the French early Strategic-AE. However, in the event of a high intensity conflict, a combination of these two doctrines could be useful.

Objectives. - Medical evacuations from foreign settings are a major health and strategic problem for the armed forces. This work aimed to study the characteristics of French military evacuations due to infectious diseases. Patients and methods. - We performed a retrospective study based on the registers of the French operational military staff for health to assess the characteristics of the strategic medical evacuation of French armed forces members on missions abroad between January 1, 2011 and December 31, 2016. Results. - Out of 4633 included cases, 301 medical evacuations (6.5%) were carried out due to infectious situations. More than half of patients were repatriated to surgical wards (162 patients, 54%), 108 patients (36%) to medical wards, 21 patients (7%) to intensive care units, six patients (2%) to an armed forces medical center, and four files (1%) were incomplete. Among infectious emergencies, malaria led to 30 evacuations (10%) including 11 to intensive care units and one death before evacuation. Infectious diseases requiring medical evacuation were most often mild and community-acquired. Most soldiers were evacuated without medical assistance. Conclusions. - Infectious diseases during missions and medical repatriations carried out for infectious reasons are important epidemiological indicators to monitor. They make it possible to adapt preventive measures, training, and diagnostic and therapeutic tools which can be made available to front-line military physicians. (C) 2019 Elsevier Masson SAS. All rights reserved.

BACKGROUNDFrench military operations in the Sahel conducted since 2013 over more than 5 million square kilometers have challenged the French Military Health Service with specific problems in prolonged field care. STUDY DESIGN AND METHODSTo describe these challenges, we retrospectively analyzed the prehospital data from the first 5years of these operations within a delimited area. RESULTSOne hundred eighty-three servicemen of different nationalities were evacuated, mainly as a result of explosions (73.2%) or gunshots (21.9%). Their mean number evacuation was 2.2 (minimum, 1; maximum, 8) per medical evacuation with a direct evacuation from the field to a Role 2 medical treatment facility (MTF) for 62% of them. For the highest-priority casualties (N=46), the median time [interquartile range] from injury to a Role 2 MTF was 130 minutes [70 minutes to 252 minutes], exceeding 120 minutes in 57% of cases and 240 minutes in 26%. The most frequent out-of-hospital medical interventions were external hemostasis, airway and hemopneumothorax management, hypotensive resuscitation, analgesia, immobilization, and antibiotic administration. Prehospital transfusion (RBCs and/or lyophilized plasma) was started three times in the field, two times during helicopter medical evacuation, and five times in tactical fixed wing medical aircraft. Lyophilized plasma was confirmed to be particularly suitable in these settings. One of the specific issues involved in lengthy prehospital time was the importance to reassess and convert tourniquets prior to Role 2 MTF admission. CONCLUSIONMain challenges identified include reducing evacuation times as much as possible, preserving ground deployment of sufficiently trained medics and medical teams, optimization of transfusion strategies, and strengthening specific prolonged field care equipment and training.

Ultrasound (US) guided needle positioning is safer than anatomical landmark techniques for central venous access. Hand–eye coordination and execution time depend on the professional's ability, previous training and personal skills. Needle guidance positioning systems (GPS) may theoretically reduce execution time and facilitate needle positioning in specific targets, thus improving patient comfort and safety.Three groups of healthcare professionals (41 anaesthesiologists and intensivists, 41 residents in anaesthesiology and intensive care, 39 nurse anaesthetists) were included and required to perform 3 tasks (positioning the tip of a needle in three different targets in a silicon phantom) by using successively a conventional US-guided needle positioning and a needle GPS. We measured execution times to perform the tasks, hand–eye coordination and the number of repositioning occurrences or errors in handling the needle or the probe.Without the GPS system, we observed a significant inter-individual difference for execution time (P < 0.05), hand–eye coordination and the number of errors/needle repositioning between physicians, residents and nurse anaesthetists. US training and video gaming were found to be independent factors associated with a shorter execution time.Use of GPS attenuated the inter-individual and group variability. We observed a reduced execution time and improved hand–eye coordination in all groups as compared to US without GPS. Neither US training, video gaming nor demographic personal or professional factors were found to be significantly associated with reduced execution time when GPS was used.US associated with GPS systems may improve safety and decrease execution time by reducing inter-individual variability between professionals for needle-handling procedures.

INTRODUCTION:Haemorrage is the leading cause of death after combat related injuries and bleeding management is the cornerstone of management of these casualties. French armed forces are deployed in Barkhane operation in the Sahel-Saharan Strip who represents an immense area. Since this constraint implies evacuation times beyond doctrinal timelines, an institutional decision has been made to deploy blood products on the battlefield and transfuse casualties before role 2 admission if indicated. The purpose of this study was to evaluate the transfusion practices on battlefield during the first year following the implementation of this policy.MATERIALS AND METHODS:Prospective collection of data about combat related casualties categorized alpha evacuated to a role 2. Battlefield transfusion was defined as any transfusion of blood product (red blood cells, plasma, whole blood) performed by role 1 or Medevac team before admission at a role 2. Patients' characteristics, battlefield transfusions' characteristics and complications were analysed.RESULTS:During the one year study, a total of 29 alpha casualties were included during the period study. Twenty-eight could be analysed, 7/28 (25%) being transfused on battlefield, representing a total of 22 transfusion episodes. The most frequently blood product transfused was French lyophilized plasma (FLYP). Most of transfusion episodes occurred during medevac. Compared to non-battlefield transfused casualties, battlefield transfused casualties suffered more wounded anatomical regions (median number of 3 versus 2, p = 0.04), had a higher injury severity score (median ISS of 45 versus 25, p = 0,01) and were more often transfused at role 2, received more plasma units and whole blood units. There was no difference in evacuation time to role 2 between patients transfused on battlefield and non-transfused patients. There was no complication related to battlefield transfusions. Blood products transfusion onset on battlefield ranged from 75 min to 192 min after injury.CONCLUSION:Battlefield transfusion for combat-related casualties is a logistical challenge. Our study showed that such a program is feasible even in an extended area as Sahel-Saharan Strip operation theatre and reduces time to first blood product transfusion for alpha casualties. FLYP is the first line blood product on the battlefield.

Les douleurs du pied sont fréquentes et parfois très handicapantes, notamment chez le sportif. L’anatomie complexe de cette région et les étiologies multiples peuvent entraîner un retard diagnostique conséquent. Parmi les causes de ces douleurs, le syndrome de l’os naviculaire accessoire est à connaître car il est facilement diagnostiqué et traité si on sait le rechercher. Nous rapportons le cas d’une jeune sportive présentant un syndrome de l’os naviculaire accessoire, évoqué devant l’apparition de douleurs de la face médiale du pied au cours d’efforts répétés. Devant l’inefficacité du traitement médical bien conduit, la patiente a bénéficié d’une prise en charge chirurgicale qui a permis la régression complète de ses symptômes. Le diagnostic précoce du syndrome a permis une reprise de l’activité sportive sept mois après l’apparition des douleurs.

INTRODUCTION:Upper Airways digestive tract cancers are the 4th more frequent cancer. They are responsible for non specific symptoms. The examination of this antomical region is very difficult for a general practitioner. The precoce diagnosis of these cancers is based on the good recognition of the clinical situations by the general practitioner. The aim of this study was to test the practice of the general practitioner in front of clinical situations typical of head and neck cancers by a Script test concordance.METHOD:The study was performed on 107 parisian general practitioners who answered a questionnaire based on a Script Concordance Test (SCT). The SCT is a questionnaire that test the clinical way of thinking comparing the use of an information of experts versus non experts.RESULTS:The answers of the practitioners tested were quite in accordance with the panel of experts' anwers. They were particularly good concerning the risk factors and the buccal and oropharyngeal cancers. The scores were lower concerning the nasopharyngeal, laryngeal and paranasal sinuses cancers. The scores were significantly better for the most experimented practitioners.DISCUSSION:The fact that the rhinopharygeal, the laryngeal and the paranasal sinuses cancers are less frequent and the fact that these cancers can not be seen directly during a standard physical examination of general practitioner can explain the lower scores for these types of head and neck cancers. That is why practitioners have to be particularly aware of the symptoms and have to ask a specialized advice in case of doubt.

Upper digestive and respiratory tract cancers represent, in frequency, the fourth cancer in the general population. They are responsible of non-specific symptoms. Clinical examination of this anatomical region is difficult for a layman for whom the specific material is not available to diagnose a small tumour The objective of this paper was to make more sensitive the general practictioners about these type of cancers.

Visitor attractions (VAs) play a crucial role in the success of a tourism destination, where they act as key motivators for visits and as resources for local communities. The range of stakeholders involved means their effective management is of key importance in the destination and in the overall success of a country's tourism product, yet they are an under-researched sector of the tourism system. This Progress in Tourism Management paper reviews and reflects on research publications in relation to this sector. It sets the wider research context and identifies the key management issues experienced at VAs. The paper identifies the limitations of current work in this field and establishes how factors such as ownership and visitor volume help to explain the complexities encountered in managing VAs. The paper then covers a set of themes to structure discussion of previous research activity and offers a model of factors involved in the effective management of VAs. The paper concludes with the development of a research agenda for VA researchers.