Le cas clinique du mois : intoxication accidentelle à dose potentiellement létale d'acide borique

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Breaking Bad News: the TAKE five program

Introduction For years, bad news delivery’s impact on patients or their relatives, as well as physicians’ stress has been a major concern. Based on studies claiming the efficacy of training courses to help physicians delivering such news, many protocols, like SPIKES, BREAKS or SHARE, have emerged worldwide. However, training to such protocol might be time-consuming and not suitable with junior doctors or trainees’ turnover. We hypothesised that a standardized 5-hours training program could improve bad news delivery practice. Participants and methods This preliminary study was conducted in the ED of a tertiary care academic hospital accounting for 90000 ED census per year, 16 attending physicians, 10 junior residents, and 5 trainees per month. Data were collected between November 2015 and April 2016. The study included 3 phases over 4 weeks. Video recorded single role-playing sessions happened the 1st (T1) and the 4th (T3) weeks. A 3-hour theory lesson happened the second week (T2), introducing the basics of therapeutic communication and delivering bad news. Each role-playing session lasted almost 1 hour (10 minutes briefing and medical case reading, 10 minutes role-plays and 40 minutes group debriefing). Bad news delivery performance was evaluated by a 14-points retrospective assessment tool (1). We collected data about the status and impact of a stressful event at 3-days using the French version of the IES-R scale (2). We applied Student t-tests for statistical analysis. Results 14 volunteers (10 trainees and 4 junior emergency physicians) were included in the study. On average, bad-news delivery process took 9’45’’ at T1 and 10’20’’ at T3. From T1 to T3, bad-news delivery performance increased significantly for both junior emergency physicians and trainees (p=0.0003 and p=0.0006, respectively). Further analysis revealed that most relevant increases involved the “situation” (p<0.001), “presentation” (p=0.009), “knowledge” (p=0.037), “emotions” (p=0.01) and “summary” (p=0.001) steps. We also found a significant decrease of the impact of bad-news delivery on trainee physicians’ stress (p=0.006). Discussion and conclusion These preliminary results indicate some potential for this new standardized course of bad news delivery. Apart from allowing physicians increase their communications skills, we believe that this simple 5-hour simulation-training program could alleviate physicians’ stress when they happen to break bad news. References 1. Brunet, A. et al. (2003). Validation of a French version of the Impact of Event Scale-Revised. Can J Psychiatry, 48(1), 56-61. 2. Park, I. et al. (2010). Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol. J Emerg Trauma Shock, 3(4), 385-388

Commentary: Dispatcher-Assisted Telephone Cardiopulmonary Resuscitation Using a French-Language Compression-Ventilation Pediatric Protocol

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Superior vena cava syndrome in a patient with large intravascular mediastinal sarcoma

peer reviewedThe superior vena cava (SVC) syndrome associates a series of signs and symptoms caused by an obstruction of the superior vena cava. The etiologies are multiple, but the most common cause is external compression of this vein by a tumor process. The present report concerns a young female with SVC syndrome. The etiology has been shown to be extra-skeletal Ewing's sarcoma extending from the right atrium to the left brachiocephalic trunk and right humeral vein. This diagnosis of tumor was delayed in the present clinical case and the patient developed serious iatrogenic complications during the early hospital management.Le syndrome de veine cave supérieure (SVCS) associe une série de manifestations liées à une obstruction de la veine cave supérieure. Les étiologies en sont multiples, mais la cause la plus fréquente de ce syndrome est une compression externe de la veine par un processus tumoral. Le cas rapporté est celui d’une jeune patiente présentant un SVCS pour lequel l’étiologie se révélera être un sarcome d’Ewing extra-squelettique s’étendant de l’oreillette droite au tronc brachio-céphalique gauche et à la veine humérale droite. Ce diagnostic de masse néoplasique ne sera toutefois posé que tardivement et la patiente développera diverses complications iatrogènes graves durant sa prise en charge hospitalière initiale

Pharmacotherapy of most severe forms of alcohol withdrawal

peer reviewedAcute alcohol withdrawal is a frequent medical condition among hospitalized patients. Severe forms are associated with significant morbidity and mortality, which can be sharply reduced with proper drug therapy. A good understanding of the pathophysiology as well as the pharmacokinetic and pharmacodynamic properties of the various drug used is paramount. The medications must target the imbalance between inhibitory and excitatory neurotransmitter systems responsible for the clinical picture. Proper drug therapy allows not only rapid symptomatic relief but also limit disease progression and complications while diminishing resource use, notably invasive ventilation and stay duration in the intensive care unit. GABA agonist drugs are the first line treatment, notably benzodiazepines and barbiturates. Other class, such as alpha-2 adrenoreceptor agonists may be used to control the dysautonomic features of the disease but are at best adjunctive. © 2019 Revue Medicale de Liege. All rights reserved

The current state of simulation in medical education

peer reviewedTraining methodology having emerged primarily over the last two decades, simulation in health care has arisen from the idea that students should never practice on the patient for their "first time". Simulation makes it possible to try out the errors and to repeat the skills over and over, in a reproducible way and in the most realistic possible environment, but with no harm to the patients, a risk socially intolerable. Simulation implies multiple methods from simple role-playing schemes to most powerful experiments on high-fidelity mannequins. In all cases, simulation implies a strictly codified structure: briefing, scenario, then debriefing. Indeed, debriefing represents the cornerstone of the teaching process allowing, both technical and non-technical skills acquisition through a work based on self-criticism. It should be noticed however that, although medical simulation has very clearly provided evidence of its effectiveness in skills acquisition, appropriate behaviours or application of algorithms, it has not demonstrated any benefit in terms of patients' care quality. Further research is therefore needed to validate this last assumption, which represents the very objective of any evolution in medicine