PORTAL-S
PhDs in EM
Please let us know if you are working on a PhD yourself or if there are interesting PhDs ongoing at your university!
PHILIPPE DEWOLF
Cardiac arrest is a dynamic condition, presenting a significant challenge that tests the technical and non-technical skills of healthcare personnel to their limits. This manuscript primarily explores the role of Advanced Cardiovascular Life Support (ACLS) in the chain of survival. ACLS relies on algorithms that delineate each step in terms of content and timing. Despite evidence-based ACLS guidelines emphasizing the quality of CPR, there remain several issues regarding CPR quality during cardiac arrest, necessitating additional efforts to improve adherence to these guidelines among resuscitation teams.
To this end, we investigated potential areas for improvement and the gaps encountered in daily practice, as well as how actual performance diverges from guideline recommendations. The ProRea Study is the first to video record cardiac arrests outside the emergency setting, allowing for a detailed prospective examination of all critical steps during resuscitation performed by Mobile Medical Teams (MMTs). We first confirmed that the awareness of being observed did not influence team behavior, effectively refuting the 'Hawthorne effect' or 'observer effect'. This validation indicates that video recording, under the conditions of our study, can be safely used as a tool for analyzing cardiac arrest performance, offering significant value in data registration and quality monitoring.
Through the analysis of these recordings, we assessed adherence to guidelines for crucial steps in the ACLS algorithm. We identified potentially avoidable factors responsible for interruptions in chest compressions, investigated the search for reversible causes, and evaluated the coordination of time-critical actions. Additionally, we examined how teamwork, leadership, and communication impact healthcare professionals' performance in real-life resuscitations.
Despite the understanding that minimizing interruptions in chest compressions is critical for maintaining coronary and cerebral perfusion pressure and increasing the chance of Return of Spontaneous Circulation (ROSC), challenges in reducing hands-off time persist. We found that 33% of CPR interruptions exceeded the recommended 10 seconds, with the most common reasons being prolonged rhythm checks, incorrect use of mechanical chest compression devices, changes in personnel performing compressions, and tracheal intubation.
There is an urgent need to make prehospital healthcare workers aware of time losses during critical actions. Time-sensitive training could enhance awareness and optimize daily practice. Our observations revealed that more than 75% of out-of-hospital cardiac arrests deviated from guidelines. Regarding airway management, the initial endotracheal intubation success rate was 69.5%. In 20.3% of resuscitations, more than two attempts were needed for intubation, and in 25.8%, chest compressions were interrupted for over 10 seconds. Capnography was used in only 63% of intubations. Additionally, epinephrine and amiodarone were frequently administered before the third shock, contrary to ACLS recommendations.
In approximately one-fourth of the recorded resuscitations, MMTs did not perform an etiologic evaluation. When conducted, the median time from arrival to start of evaluation was 4 minutes for out-of-hospital cardiac arrests (OHCA) and 4 minutes 15 seconds for in-hospital cardiac arrests (IHCA). In 80% of evaluations, emergency physicians employed the 4Hs and 4Ts system. Heteroanamnesis and medical history questioning were the preferred methods, while clinical examinations and technical investigations were less commonly used. MMTs often failed to initiate treatment promptly, taking up to twice the recommended time, which underscored the significant correlation between timely etiologic evaluation and ROSC.
A systematic review assessed the impact of non-technical skills (NTS) training on performance in ACLS simulations, demonstrating that team simulation training improves NTS and reduces the time to complete a simulated cardiac arrest. Feedback during debriefing and repetitive practice were identified as crucial elements for training NTS, although the benefits persisted for only about 3 to 6 months.
The analysis of CA video recordings using the validated Team Emergency Assessment Measure (TEAM) tool revealed that effective team communication scored the lowest, whereas composure, control, and adherence to guidelines scored the highest. The results from the ProRea study will inform recommendations for optimal ACLS training for healthcare providers.
Emphasizing a time-specific approach during simulation training is vital. Recognizing areas for improvement is a crucial first step. Enhancing the Chest Compression Fraction (CCF) through targeted training on specific technical activities is essential. Additionally, the approach to etiologic evaluation needs further exploration to streamline and potentially incorporate technical aids like ultrasound.
Articles:
* Dewolf P, Rutten B, Wauters L, van den Bempt S, Uten T, van Kerkhoven J, et al. Impact of video-recording on patient outcome and data collection in out-of-hospital cardiac arrests. Resuscitation 2021;165:1–7. https://doi.org/10.1016/j.resu....
* Dewolf P, Wauters L, Clarebout G, van den Bempt S, Uten T, Desruelles D, et al. Assessment of chest compression interruptions during advanced cardiac life support. Resuscitation 2021;165:140–7. https://doi.org/10.1016/j.resu....
* Dewolf P, Wauters L, Clarebout G, Elen J. Timing and identification of the cause and treatment of a cardiac arrest: a potential survival benefit? Med Princ Pract 2022. https://doi.org/10.1159/000525....
* Dewolf P, Clarebout G, Wauters L, van Kerkhoven J, Verelst S. The Effect of Teaching Nontechnical Skills in Advanced Life Support: A Systematic Review. AEM Educ Train 2020:aet2.10522. https://doi.org/10.1002/aet2.1....
* Dewolf P, Vanneste M, Desruelles D, Wauters L. Measuring non-technical skills during prehospital advanced cardiac life support: A pilot study. Resusc Plus 2021;8:100171. https://doi.org/10.1016/J.RESP....
* van den Bempt S, Wauters L, Dewolf P. Pulseless electrical activity: Detection of underlying causes in a prehospital setting. Medical Principles and Practice 2021;30:212–22. https://doi.org/10.1159/000513....
* Dewolf P, Arnout PJ, van den Bempt S, Uten T, Loots K, Wauters L. When time is of the essence: comparison of the resuscitation time frame recommended by the ALS guidelines and daily practice. https://doi.org/10.29011/2475-...
FLORENCE DUPRIEZ
Point of Care UltraSound (PoCUS) is used bedside as part of the clinical examination. Although its clinical integration is currently being promoted in the medical world and facilitated by the improved portability and reduced cost of ultrasound machines, there is still a pressing need to evaluate its diagnostic accuracy, its impact on the diagnostic approach, as well as PoCUS education.
PoCUS can be used in many ways during the clinical examination. The following analysis mainly focuses on PoCUS use to assess the right upper quadrant (RUQ) of the abdomen by collecting data about PoCUS diagnostic accuracy for gallbladder assessment, evaluating the impact of PoCUS of the RUQ on the diagnostic approach, and exploring PoCUS teaching opportunities among undergraduate medical students along with the current state of PoCUS education in medical faculties throughout Europe.
In some cases, the boundaries between comprehensive ultrasound performed in radiology and PoCUS are difficult to define, which may lead to tensions between different medical societies. This seems particularly true for PoCUS of the abdomen. Although cardiac ultrasound is mainly performed by cardiologists, and X-ray and computed tomography are favored over ultrasound for lung monitoring, abdominal ultrasound is still the modality of choice to investigate the abdomen, especially in the case of RUQ pain. Differentiating the need for abdominal PoCUS instead of comprehensive ultrasound can therefore be difficult. PoCUS is nevertheless part of the clinical examination and therefore differs from comprehensive ultrasound on account of its bedside use during the clinical examination prior to the planning of other complementary investigations in the overall diagnostic approach.
Among other estimates, sensitivity and specificity are essential to appreciate the diagnostic accuracy of a diagnostic tool and to estimate post-test results integrated into the clinical approach. To address this specific issue, the initial research intention of this PhD was the conduct of a systematic review, which aimed to determine the agreement between PoCUS and RADUS in the evaluation of the gallbladder to identify cholelithiasis or cholecystitis in the ED. These estimates are nevertheless not the only aspect to consider when evaluating the overall diagnostic approach, which raised the issue of the clinical utility of PoCUS rather than its diagnostic accuracy alone. Differential diagnosis is not the only substantial item of the overall diagnostic approach. Therefore, as any effective diagnostic approach should have a differential diagnosis list, treatment plan, and choice of complementary diagnostic tests deemed to be consistent with the final diagnosis, the second research intention of this PhD was to investigate the contribution of PoCUS to the overall diagnostic approach in the case of RUQ abdominal pain in the ED. As it was shown that PoCUS enhances the overall diagnostic approach bedside and consequently the clinical examination, this could support the inclusion of PoCUS training in medical school curricula, as all medical students should be taught the best possible diagnostic approach. At present, medical schools are beginning to progressively introduce PoCUS into their curricula following the spread of its clinical use. In a position statement published in 2015, the American Academy of Emergency Medicine followed by the European Federation of Societies for Ultrasound in Medicine and Biology in 2016 recommended including PoCUS training in medical school undergraduate curricula to improve the learning of core concepts and to develop students’ understanding of physical examinations. Despite these recommendations, there is limited literature about how to effectively teach PoCUS to large numbers of students. Focusing on the RUQ of the abdomen and based on the importance of gallstone findings when using PoCUS, as a third research intention, this PhD evaluated the feasibility of teaching gallbladder PoCUS to undergraduate students according to a method of practical teaching using exclusively normal PoCUS patterns. Studying PoCUS undergraduate teaching raised the additional question of the state of undergraduate PoCUS teaching. To address this question, a questionnaire study sent to medical faculties in the European Union (EU) provided insights into the current state of PoCUS education in medical schools. This doctoral dissertation then put forward a perspective into how PoCUS could become part of clinical examination teaching.
Link to PhD
https://dial.uclouvain.be/pr/boreal/object/boreal:284692
Articles:
* F.Dupriez, P. Geukens, A. Penaloza ; D. Vanpee , G. Bekkering, X. Bobbia. Agreement of Emergency Physician-Performed Ultrasound versus Radiology- Performed Ultrasound for Cholelithiasis or Cholecystitis: A Systematic Review Eur J Emerg Med. 2021 Oct 1;28(5):344-351.
* Dupriez F, de Castro BR, Gendebien F, Fasseaux A, Gensburger M, Marissiaux L, Penaloza A, Bobbia X, Jarman R. Is gallbladder PoCUS diagnostic accuracy accessible to medical students after PoCUS training exclusively on healthy volunteers? A pilot randomized control trial. Ultrasound J. 2023 Apr 10;15(1):18. doi: 10.1186/s13089-023-00317-6. PMID: 37036612.
* Dupriez F, Niset A, Couvreur C, Marissiaux L, Gendebien F, Peyskens L, Germeau B, Fasseaux A, Rodrigues de Castro B, Penaloza A, Vanpee D, Bobbia X. Evaluation of point-of-care ultrasound use in the diagnostic approach for right upper quadrant abdominal pain management in the emergency department: a prospective study. Intern Emerg Med. 2023 Dec 2. doi: 10.1007/s11739-023-03480-9. Epub ahead of print. PMID: 38041765.
* Dupriez, F., Jarman, R. D. (2024). Normology: Is it Time to Rethink Point-of-Care Ultrasound Training? Journal of Medical Education and Curricular Development, 11.
* Dupriez F, Hall A, Diop T, Collard A, de Castro BR, Smets F, Penaloza A, Vanpee D. Point-of-Care Ultrasound training in undergraduate education in the European Union: current situation and perspectives. Ultrasound J. 2024 Feb 13;16(1):9. doi: 10.1186/s13089-024-00361-w. PMID: 38349580.
ALLISON GILBERT
PhD Editorial
Emergency department (ED) overcrowding is responsible for many adverse events, decreasing the quality and safety of care. Therefore, managing the patient flow is a significant challenge in overcrowded emergency services. In a healthcare system struggling to deal with a growing demand for care, it is essential to ensure patient safety by considering appropriate operational strategies to direct patients to the right place, at the right time, with the appropriate healthcare professional. Various opportunities for regulating ED patient flows can be explored, from clinical decision support tools to guide the patient to the most appropriate level of care to innovative triage systems and pathways of care within departments.
Within the hospital setting, triage systems represent an indispensable tool for patient safety, categorizing the severity of their problem on admission and assigning them an optimal time to first medical contact. Triage systems are complex and composed of 3 main elements: the operator (responsible for the patient assessment), the scale (protocols to identify the severity of the patient’s condition) and the methodology (strategies to dispatch the patient). Although robust and valid triage systems are described, classical approaches seem to be vulnerable to overcrowding and partially succeed in reintegrating the patient into the most appropriate care pathway inside the EDs. New perspectives on triage systems in EDs are needed, and the era of digital health and artificial intelligence could offer some opportunities.
In line with this statement, in the prehospital setting, one exciting triage approach considers using new digital health applications to augment the triage process. Indeed, new strategies of patient flow management investigated the opportunity to consider the patient as the operator of the triage procedure and involve him in his own "self-triage". Although this concept seems to be feasible and safe, it implies the creation of intuitive self-triage tools that must be usable, valid and easily accessible to all.
Ultimately, ED overcrowding is an international public health issue that goes beyond a department’s four walls. Collaborative pathways of care involving primary care providers and emergency physicians could represent an opportunity to manage the still growing demand for care. Implementing original alternative care centers requires the consideration of an appropriate redirection procedure. Redirection operations imply not only the use of a valid triage scale but also the implementation of a new and safe care pathway.
Link to PhD
https://orbi.uliege.be/handle/2268/303413
Articles
Gilbert A, Diep AN, Boufraioua M, Pétré B, Donneau AF, Ghuysen A. BMC Health Serv Res. 2022 Sep 23;22(1):1199. doi: 10.1186/s12913-022-08571-5.
* [New method to regulate unscheduled urgent care : the ODISSEE interactive self-triage platform].
Gilbert A, Brasseur E, Ghuysen A, D'Orio V. Rev Med Liege. 2020 Mar;75(3):159-163.
Brasseur E, Gilbert A, Donneau AF, Monseur J, Ghuysen A, D'Orio V. Acta Clin Belg. 2022 Jun;77(3):640-646. doi: 10.1080/17843286.2021.1936353. Epub 2021 Jun 3.
* Triage in the time of COVID-19.
Gilbert A, Ghuysen A. Lancet Digit Health. 2022 Apr;4(4):e210-e211. doi: 10.1016/S2589-7500(22)00001-2. Epub 2022 Mar 9.
Diep AN, Gilbert A, Saegerman C, Gangolf M, D'Orio V, Ghuysen A, Donneau AF. Infect Dis (Lond). 2021 Aug;53(8):590-599. doi: 10.1080/23744235.2021.1903548. Epub 2021 Apr 1.
Gilbert A, Brasseur E, Petit M, Donneau AF, D'Orio V, Ghuysen A. Acta Clin Belg. 2022 Jun;77(3):571-578. doi: 10.1080/17843286.2021.1914948. Epub 2021 Apr 15.
* Emergency department crowding: why do patients walk-in?
Brasseur E, Gilbert A, Servotte JC, Donneau AF, D'Orio V, Ghuysen A. Acta Clin Belg. 2021 Jun;76(3):217-223. doi: 10.1080/17843286.2019.1710040. Epub 2019 Dec 30.
* [SALOMON, a collaboration model between primary and secondary care for nocturnal emergency calls].
Brasseur E, Gilbert A, Servotte JC, Ghuysen A, D'Orio V. Rev Med Liege. 2020 Feb;75(2):83-88.
Gilbert A, Piazza J, Szecel J, Ancion A, Gensburger M, Lopez R, D'Orio V, Ghuysen A. Rev Med Liege. 2020 Sup;75(S1):11-17.
FARAH ISLAM
Farah Islam completed a BA in Psychology from McGill University (2016) and a MSc in Public Health from the Université de Montréal in (2018) (Montréal, Canada). In 2019, she obtained a Marie Skłodowska-Curie Fellowship from the European Commission and conducted her PhD in Biomedical Sciences at KU Leuven University (2023) (Leuven, Belgium) under the supervision of Prof. Dr. Koen Milisen and Prof. Dr. Marc Sabbe. During her PhD, she aimed to better understand and improve the accuracy of non-clinical operator led telephone-triage services in older adults seeking out-of-hours unplanned care across part of the Flemish region of Belgium.
Overall findings of her research showed that while non-clinical operator led out-of-hours telephone triage services may generally be a safe, and efficient tool for managing unplanned care needs across the population, there still remains large room for improvement with regards to the use of these services for older patients. Although this presented a first step towards addressing this gap in the literature, this research presented important findings to prompt future efforts that are required for improving existing models of care for older adults.
Articles
* Islam, F., Milisen, K., Gellens, M., Enckels, J., Kocot, E., Sowada, C., Sabbe. (2022). Changes in the use and uptake of a national out-of-hours telephone triage service by younger and older patients seeking non-urgent unplanned care surrounding the COVID-19 pandemic in Flanders (Belgium). Acta Clinica Belgica, 1-9. https://doi.org/10.1080/17843286.2022.2068296
* Mooijaart, S., Lucke, J., Heeren, P Singler, P., McNamara, R., Gilbert, T., Nickel, C., Castejon, S., Mitchell, A., Mezera, V., Van der Linden, L., Lim, S., Thaur, A., Karamercan, M., Blomaard, L., Islam, F., Dundar Z., Cheung K, De Groot, B., Conroy, S. (2021). Providing care for older adults in the Emergency Department: expert clinical recommendations from the European Task Force on Geriatric Emergency Medicine. European Geriatric Medicine, 13(2), 309-317. https://doi.org/10.1007/s41999-021-00578-1
* Islam, F., Sabbe, M., Heeren, P., Milisen, K. (2021). Consistency of decision support software‑integrated telephone triage and associated factors: a systematic review. BMC Medical Informatics and Decision Making, 21(107), 1-10. https://doi.org/10.1186/s12911-021-01472-3
NICOLAS DELVAU (UCL)
EARLY CARE MANAGEMENT AFTER CARBON MONOXIDE POISONING BASED ON CARBOXYHEMOGLOBIN TOXICOKINETIC: ON NON-INVASIVE VENTILATION AFTER ACUTE CARBON MONOXIDE EXPOSURE ON SWINE MODEL.
This thesis addresses the toxicokinetics of carboxyhaemoglobin (COHb) after acute carbon monoxide (CO) intoxication treated by non-invasive ventilation on a swine model. This toxicokinetic approach confirms a bi-compartmental elimination of COHb in general and suggests that calculation of the COHb half-life (COHbt1/2) could be useful for estimating the extra-vascular CO storage and the severity of CO intoxication. In addition, for the first time, we observed a rebound in COHb after treatment on normobaric oxygenation.
In addition, we published the largest review of the affinity of CO for hemoglobin (M value) in the animal world, which varies according to species, and we confirm the human M value at 218. This value should become the reference in the literature on CO. In the light of these results, we propose recommendations for clinicians and for future studies on the subject.
Articles:
* Delvau N, Penaloza A, Liistro G, Thys F, Delattre IK, Hantson P, et al. Effect of Pressure Support Ventilation on Carboxyhemoglobin Toxicokinetic after Acute Carbon Monoxide Intoxication: a Swine Model. J Med Toxicol. 2018;14(2):128-33.
* Delvau N, Penaloza A, Liistro G, Thys F, Megarbane B, Hantson P, et al. Relative Affinity M Constant of Adult and Fetal Hemoglobin for Carbon Monoxide in Humans: a Systematic Review and Meta-Analysis. Human Physiology. 2020; 46:191-9.
* N. Delvau, A. Penaloza, G. Liistro, F. Thys, B. Megarbane, Ph. Hantson, PM Roy. Report on the relative affinity constant (M) of hemoglobin for carbon monoxide in the animal world: a comparative review with a meta-analysis based on a systematic review. Journal of Evolutionary Biochemistry and Physiology, 2019, Vol.55, N°5, PP 348-364.
* N. Delvau, L. Elens, A. Penaloza, G. Liistro, F. Thys, P.M. Roy, P. Gianello, P. Hantson. Carboxyhemoglobin half-life toxicokinetic profile during and after normobaric oxygen therapy: on a swine model. Toxicology Reports (Submitted; Jun 01 2023).
* N. Delvau, A. Penaloza, V. Franssen, F. Thys, P.M. Roy, Ph. Hantson. Unexpected carboxyhemoglobin half-life during cardiopulmonary resuscitation: a case report. International Journal of Emergency Medicine (2023) 16:22.
FOAMED FOR U
- Discover the GO Doctor! game.
This is an educational game based on the evidence-based methodology "serious gaming" and developed in collaboration with leading belgian academic clinicians - www.go-doctor.eu - LITFL (Life in the Fastlane) - www.lifeinthefastlane.com
- EmCrit (Emergency Departement Critical Care) - www.emcrit.org
- REBEL EM (Rational Evidence Based Evaluation of Literature in Emergency Medicine) - www.rebelem.com
- Emergency medicine cases - https://emergencymedicinecases...
- Journal Feed - https://journalfeed.org
- The resus room - www.theresusroom.co.uk
- HippoED - www.hippoed.com
- ALiEM - https://www.aliem.com
- SAEM (Society for Academic Emergency Medicine) - https://www.saem.org/education/saem-online-academic-resources/foamed-resources
- ST.EMLYN’S: www.stemlynsblog.org
- The skeptic’s guide to EM: thesgem.com
- The EM STUDENT PROJECT: Welcome! – International Emergency Medicine Education Project (iem-student.org)
INTERESTING WEBSITES:
- EUSEM - https://eusem.org
- ERC - https://www.erc.edu
PROTOCOLS: - UZ Gent -https://uzgent.be/urgent
- RENAU (Le Reseau Nord Alpin des Urgences) - https://www.renau.org
- Urg’Ara (Région Auvergne-Rhône-Alpes) - https://www.urgences-ara.fr
Presentations congress may 2024
Keynote: We are all war doctors - Kol. A. Van Rompay
Extraordinary: The outback - C. Duchatelet
Extraordinary: The mountains - J. Petit
Extraordinary: The pitch - J. Devloo
The most influential papers of 2022-2024 - A. Penaloza
AI in acute cardiology: The omi paradigm - T. Versyck & T. Balthazar
SNAP: A Belgian National Sepsis Action Plan - E. Vlieghe, I. Malfait, P Van de Voorde
Keynote: AI and EM – A bright future - C. Gil-Jardine, A. Gilbert
Workshop: Difficult airways - E. Steen, N. Cleymans, C. Haentjens
Workshop: Belly ultrasound - F. Dupriez, G. Nada
Workshop: Ventilation made easy - J. Fierens, S. Malinverni
Workshop: First 30 minutes of a (CBRNe) disaster - J. Vaes, K. Segerink, I. Demeyer
Intoxications that kill u - K. De Baedemaeker
Peripheral nerve blocks - G. Nada
Palliative emergencies - A. Coulon, F. Steenebruggen
Interesting articles
- Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement
- Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning A Randomized Clinical Trial
- Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial
- Do emergency medicine health care workers rate triage level of chest pain differently based upon appearance in simulated patients?
- Peripheral Administration of Norepinephrine A Prospective Observational Study
- State of the Art: Acute Encephalitis
- Evaluation and management of cauda equina syndrome in the emergency department
- High risk and low prevalence diseases: Blast injuries
- Role of preoperative in-hospital delay on appendiceal perforation while awaiting appendicectomy (PERFECT): a Nordic, pragmatic, open-label, multicentre, noninferiority, randomised controlled trial
- Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med. 2023 May
- Diagnosis and Management of Priapism. JAMA. 2023 Aug
- High risk and low prevalence diseases: Thyroid storm. Am J Emerg Med. 2023 Jul
- High risk and low prevalence diseases: Orbital cellulitis. Am J Emerg Med. 2023 Jun
- Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. NEJM Jun
PODCAST
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SPOEDCAST
Dr. Cédric Van Dijck, dr. Ruben Haesendonck en dr. Pieter Jan Van Asbroeck worked hard to provide us these episodes - CHECK THEM OUT! Feedback via facebook #Spoedcast of via spoedcast@gmail.com
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VLUG-CAST
Our friends from the VLUG also made a podcast, the VLUG-Cast, check it out here: VLUG-cast | Podcast on Spotify ENJOY!
THE RESUS ROOM PODCAST (UK) - www.theresusroom.co.uk
CANADIEM CRACKCAST (Canada) - https://canadiem.org/crackcast
SFMU PODCAST (France): Urgences Le Mensuel - https://www.sfmu.org/fr/formation/webinar