Comprehension is poor in patients admitted in the emergency observation unit. Teamwork communication gaps could contribute to patients' misunderstanding of their health condition. To determine in patients admitted in the emergency observation unit whether comprehension of diagnosis, prognosis, and management depended on nurses' comprehension, the authors conducted a prospective observational study in a busy adult emergency department of a tertiary teaching hospital in Paris over 2 months. Consecutive patients admitted in the emergency observation unit were included. Patients' and nurses' comprehension of diagnosis, prognosis, and management was compared with the statements of the emergency department attending physicians for these items. The authors observed whether patients' misunderstanding was associated with nurses' misunderstanding. A total of 544 patients were evaluated. For each patient, nurses' and patients' comprehension was available. Patients understood severity in 40%, organ involved in 69%, medical wording in 57%, reason for admission in 48%, and discharge instruction in 67%. In comparison with patients, nurses better understood each item except for discharge instruction. The authors observed that patients' comprehension was better when nurses understood diagnosis (p <.0001), reasons for admission (p =.032) and discharge instructions (p =.002). Nurses' understanding of severity did not modify patients' comprehension. These results support the conclusions that communication gaps in teamwork alter patients' comprehension and that nurses' and patients' misunderstandings are associated. Therefore, improving communication by nurses and physicians to patients may improve patients' understanding.

Pochi studi si sono interessati all’anemia in Pronto Soccorso, mentre questo problema è pluriquotidiano al letto del paziente per ogni urgentista. L’anemia può essere la causa del sintomo che conduce il paziente a visita e l’oggetto stesso della visita o essere scoperta al momento della presa in carico del paziente. La presenza di un’anemia pone numerose domande nel contesto dell’urgenza: quali eziologie ricercare e con quali tempi, qual è la ripercussione dell’anemia, il paziente deve essere sottoposto a una trasfusione? Lo scopo di questo capitolo è di fornire degli elementi di risposta a ciascuna di queste domande che si pone legittimamente l’urgentista di fronte all’anemia nella sua pratica clinica.

Shock is a common reason for medical intensive care unit admission, with septic and cardiogenic accounting for most of the etiologies. However, the potential severity of adverse side effects of drugs indicates that any medication should be carefully scrutinized for potential pharmacokinetic and pharmacodynamic interactions that may result. We herein report the case of a life-threatening shock mimicking successively anaphylactic, cardiogenic, and septic shock, which was finally related to disulfiram ethanol reaction. Indeed, disulfiram ethanol reaction is known to provoke unpleasant symptoms through vasodilatation in various organs. However, extreme manifestations of vasodilatory shock may lead to circulatory failure and lactic acidosis. Because of large prevalence of alcoholism and disulfiram medication, emergency physicians and medical specialists should be aware of this life-threatening condition, with its misleading presentation.

Perruche, Franck; Eche, Antoine; Der Sahakian, Guillaume; Trabattoni, Eloïse; Kierzek, Gérald; Claessens, Yann-Erick Author Information

Objective To assess the sensitivity and specificity of emergency physicians in detecting anxiety and depression in patients requiring admission to the emergency department (ED) observation care unit for complementary investigations/treatment. Methods 339 consecutive patients admitted to the emergency observation care unit of 14 EDs were interviewed with standardised questionnaires. The characteristics of the patients, EDs and attending ED physicians were collected. Patients' anxiety and depression were identified using the Hospital Anxiety and Depression Scale (HADS), a self-administered questionnaire. ED physicians were blind to the HADS score and were asked to declare whether they perceived anxiety and depression in each patient. The judgement of ED physicians and the HADS score were compared using sensitivity, specificity, positive and negative likelihood ratios. Results The HADS questionnaire was correctly completed by 310 patients who comprised the study population. HADS detected symptoms of anxiety in 148 patients (47%) and symptoms of depression in 70 patients (23%). ED physicians determined the presence or absence of anxiety with a sensitivity of 48% (95% CI 40% to 56%) and a specificity of 69% (95% CI 61% to 75%). Positive and negative likelihood ratios were 1.54 (95% CI 1.16 to 2.06) and 0.75 (95% CI 1.28 to 3.28) for anxiety. They detected the presence or absence of depression with a sensitivity of 39% (95% CI 28% to 51%) and a specificity of 78% (95% CI 72% to 83%). Positive and negative likelihood ratios were 1.75 (95% CI 1.20 to 2.56) and 0.78 (95% CI 1.26 to 3.87) for depression. Conclusion Although patients presenting to the ED often experience anxiety and depression, these symptoms are poorly detected by ED physicians.

INTRODUCTION:Febrile neutropenia (FN) is common in cancer patients receiving myelotoxic therapy. The procedures to treat FN are well established in oncology, but it is unclear whether management is adequate in the emergency department (ED). METHODS:This prospective, multicentre, observational study was carried out in 47 French EDs for 6 months. Patients were adults presenting at the ED with FN after myelotoxic treatment for cancer. Severity of infection was defined according to Bone criteria for severe sepsis and septic shock (SS/SSh) and risk was determined according to Multinational Association of Supportive Care in Cancer (MASCC) criteria. The end point was the implementation of guidelines. Management of patients with SS/SSh required: (i) adequate intravenous (IV) antimicrobial therapy for the first 90 min (broad-spectrum beta-lactam with or without an aminoglycoside); (ii) fluid challenge (500 mL); (iii) lactate measurement; (iv) at least one blood culture; and (v) hospitalization. Management of patients without SS/SSh required: (1) no initiation of granulocyte - cell stimulating factor (G-CSF); (2) adequate IV antimicrobial therapy (broad-spectrum beta-lactam) and hospitalization if the patient was high-risk according to MASCC criteria; (3) adequate oral antimicrobial therapy (quinolone or amoxicillin/clavulanate or cephalosporin) and hospital discharge if the patient was low-risk. RESULTS:198 patients were enrolled; 89 patients had SS/SSh, of whom 19 received adequate antimicrobial therapy within 90 min and 42 received appropriate fluid challenge. Blood cultures were obtained from 87 and lactate concentration was measured in 29. Overall, only 6 (7%) patients with SS/SSh received adequate management. Among 108 patients without SS/SSh, 38 (35%) were high-risk and 70 (65%) low-risk. In the high-risk group, adequate antimicrobial therapy was given to 31 patients, G-CSF was initiated in 4 and 35 were hospitalized. In the low-risk group, 4 patients received adequate oral antimicrobial therapy, IV antimicrobial therapy was prescribed in 59, G-CSF was initiated in 12 and six patients were discharged. Adequate management was given to 26/38 (68%) high-risk and 1/70 low-risk patients. Factors associated with adequate management were absence of SS/SSh (P = 0.0009) and high-risk according to MASCC criteria (P < 0.0001). CONCLUSIONS:In this French sample of cancer patients presenting to the ED with FN, management was often inadequate and severity was under-evaluated in the critically ill.

L'arrêt cardiocirculatoire (AC) représente un problème de santé publique majeur pour lequel tout médecin doit être formé. En France, l'apprentissage des gestes de réanimation cardiopulmonaire (RCP) repose sur l'obtention de l'attestation de formation aux gestes et soins d'urgence (AGFSU) durant le deuxième cycle des études médicales. L'objectif de ce travail était d'évaluer les principales connaissances théoriques des futurs médecins généralistes par rapport à la prise en charge de l'AC eut égard aux dernières recommandations.Une enquête a été réalisée auprès de 1699 internes de médecine générale d'Île-de-France à partir d'un auto-questionnaire distribué lors du choix des stages de mars 2016.Six cent quinze internes ont été inclus. Parmi, 308 internes (50 %) ont été confrontés à moins de 5 AC au cours de leurs études. Six cent deux internes (98 %) ont réalisé au moins une formation aux gestes de premiers secours. Trente-huit pour cent des internes n'ont jamais renouvelé de formation aux gestes de premiers secours. Deux cent cinquante et un internes (48 %) ont déclaré que les recommandations de la prise en charge de l'AC sont publiées tous les 5 ans. Deux cent quatre-vingt-dix-sept (48 %) ont estimé que la séquence ABC est la séquence de choix de la RCP.La connaissance, par les internes de médecine générale de Paris Île-de-France, des points principaux des dernières recommandations internationales concernant la prise en charge de l'AC est insuffisante, contrastant avec une formation théorique dispensée à l'université et une confrontation non négligeable à l'AC au cours des stages hospitaliers. En adéquation avec les besoins ressentis des médecins généralistes de demain, une mise à jour des connaissances théoriques au cours du troisième cycle des études médicales (« savoir ») paraît nécessaire, complétée par une mise en pratique via la simulation sur mannequin (« savoir-faire »), et ce, dès le début de l'internat. La prise en charge de l'AC par les internes de médecine générale de Paris Île-de-France devrait être possible par une amélioration du savoir et du savoir-faire.Cardiac arrest (CA) is a public health priority and doctors are expected to be efficient in cardio-pulmonary resuscitation (CPR). In France, medical students must complete a mandatory basic life support (BLS) course during medical training. We aim to assess the main knowledge regarding last international CPR recommendations of the residents from Paris.A cross-sectional survey was conducted among 1699 French general practitioners (GP) residents.Six hundred and fifteen GP residents were included. Three hundred eight GP residents (50%) declared an exposition lower than 5 CA during their internship. Of them, 602 (98%) received education on BLS during medical training. Thirty-eight percent of residents never renew the training. Two hundred fifty-one GP residents (48%) declared that international recommendations are published every 5 years. Two hundred and ninety-seven (48%) declared that the ABC sequence must be preferred during BLS.Last international recommendations concerning CPR are poorly known by French GP residents contrasting with a strong teaching and exposition to CA during the internship. Recycling on international recommendations concerning CPR seems to be necessary (knowledge) and completed by practical training using full-scale simulation (expertise) from the beginning of the internship. Improvement of knowledge and expertise of French GP residents from Paris by should improve care of cardiac arrest.

Comprehension is critical for patients’ satisfaction and quality of care assessment especially in the setting of emergency medicine. Our aim was to evaluate these items in patients who required admission in the emergency departments (ED) for investigations or treatment. We conducted a prospective study to evaluate the comprehension of 20 patients admitted in each of the nine participating EDs, and to determine factors associated with misunderstanding. Patients answered questionnaires about comprehension, satisfaction (Critical Care Family Need Inventory [CCFNI]), and anxiety/depression (Hospital Anxiety and Depression Scale [HADS]). Thirty patients (19%) understood diagnosis, severity, and treatment. Median CCFNI was 18, suggesting a good level of satisfaction. Patients were partially satisfied with information and did not completely trust the care they received. Intensity of depression significantly altered patients’ comprehension (three [0–14] in those who understood vs. six [0–21] in those who did not non understand). Depression should be considered in patients admitted in the emergency room as it affects their comprehension and consequently global quality of care. La compréhension par le patient de son diagnostic est fondamentale pour obtenir sa satisfaction et améliorer la qualité des soins en médecine d’urgence. Notre but a été d’évaluer la compréhension des patients hospitalisés dans les urgences pour traitement ou exploration, et de déterminer quels facteurs l’influençaient. Étude prospective observationnelle de 20 patients consécutifs dans neuf services d’urgence. Évaluation de la compréhension, de la satisfaction (critical care family need inventory [CCFNI]), et des symptômes d’anxiété/dépression (hospital anxiety and depression scale [HADS]), des critères démographiques usuels. Détermination des facteurs associés avec une mauvaise compréhension en analyse univariée. Trente patients (19 %) avaient compris le diagnostic, le pronostic et le traitement. La médiane du CCFNI était de 18, suggérant un bon niveau de satisfaction. Les patients étaient partiellement satisfaits de l’information fournie et avaient une confiance partielle dans la qualité des soins reçus. L’intensité des symptômes de dépression altérait la compréhension des patients (trois [0–14] pour les patients comprenant toutes les informations contre six [0–21] pour le reste de la population). La population des patients consultant aux urgences a un faible niveau de compréhension qui dépend au moins partiellement des symptômes de dépression.

Background Recent data, focused on the inability to transfer emergency patients to inpatient beds, has shown this to be the single most important factor contributing to overcrowding. Our Emergency Department (ED) was reorganized in the year 2000 based on the optimization of patients' flow. In this model, the emergency team had to refer patients to units fitting best to their condition with minimal delays. Objectives To evaluate adequacy of both diagnosis between emergency room and hospitalization wards and patients' orientation in the context of an early discharge from the ED. Methods We collected data from 996 consecutive nontrauma patients for whom an admission was decided. Duration of stay in the ED and all related parameters were studied. Patients were categorized according to the adequacy of the diagnosis proposed at ED discharge as compared with the final diagnosis at hospital discharge. The patients' orientation appropriateness was also assessed. Results Despite a median duration of time of 6 h (21 min–54 h) diagnostics made by the emergency physicians and the patients' orientation were considered as adequate in most of the cases (66 and 96%, respectively). Fast track developed with medical intensive care and cardiology intensive care allowed referral of patients requiring these specific units within 2.2 h (27 min–17 h) and 2 h (41 min–8 h), respectively. The ED length of stay was highly influenced by the admission location and by the patient's age. Conclusion A short time of stay in the ED is compatible with both a good diagnosis and a good orientation of ED patients requiring admission for specialized care.

Bien qu’elle fasse partie des éléments permettant d’apprécier la qualité des soins, et quoique le législateur ait rendu obligatoire son évaluation, la satisfaction des patients reste sous-évaluée dans les services d’urgence. De plus, les outils de mesure sont disparates et les indicateurs à mesurer manquent d’harmonisation. Ces éléments rendent délicate l’interprétation des résultats. Nous proposons dans cette revue de la littérature une vision synthétique des études s’intéressant à la satisfaction des patients aux urgences.

Diagnosis of acute pancreatitis relies on clinical symptoms and increase of serum lipase within 48 hours. We report the case of a patient admitted in the emergency department with a 24 hour history of acute abdominal pain. A computed tomography (CT) scan revealed an acute pancreatitis in spite of the lipase serum level being normal. An 84 year old man was referred to our emergency department because of recurrent diffuse abdominal pain and vomiting for 24 hours. He had a history of type 1 diabetes mellitus, dysarthria, and left hemiplegia related to ischaemic stroke. He has previously been operated for suspected bowel related sepsis. He also had been treated for bladder polyps 2 years ago, and had had a left nephrectomy for unknown purpose. His current treatment included subcutaneous insulin, dalteparin (2500 U/day), omeprazole (20 mg/day), and venlafaxine (75 mg/day). He was not an alcoholic and did not smoke. …