bluuebunny/crossref_metadata_2025 huggingface dataset:
The Case Of Edward Revere Osler
Authors: Starling PH
Published: March 2013

In today’s military medical environment interoperability is a regular occurrence. During the First World War a small group of eminent medical men from England and America combined their skills to endeavour to save the life of the son of another eminent physician.
The Evolution Of Casualty Evacuation In The British Army In The 20th Century (Part 3) – 1945 To Present
Authors: Bricknell MCM
Published: March 2013

This is the third in a series of papers describing the evolution of the British casualty evacuation chain during the 20th century. This period was dominated by the threat of war between NATO and the Warsaw Pact in Central Europe. The Suez Crisis in 1956, the Falklands War in 1982, the Gulf War in 1991 and events in the Balkans during the 1990s demonstrated the requirement for a flexible system for medical support to the UK Armed Forces.
Degenerative Disease In Lumbar Spine Of Military Parachuting Instructors
Authors: Bar-Dayan Yosefa , Weisbort Moshe , Bar-Dayan Yaron , Velan Gad J , Ravid Mordchai , Hendel David , Shemer Joshua
Published: March 2013

Parachuting, be it static line or skydiving, places enormous stresses on the human spine. It is, therefore, important to determine the prevalence and severity of degenerative changes in the lumbar spine of subjects who practice this sport activity.

Seventy four parachuting instructors, mean age 33 years and with an average of 410 static line and skydiving jumps, were included in the study. Past radiographs were examined and compared to current anterolateral and lateral views of the lumbar spine, in order to determine the prevalence of degenerative changes and document possible progression.

Doubtful radiographic changes in the lumbar spine were identified in 47.4 percent of the parachuting instructors, mild degeneration in 9.6 percent, moderate degenerative disease in 10.9 percent and severe radiographic changes in 5.5 percent. Schmorll nodes were found in 8.1 percent of the subjects. Traction spurs - osteophytes were identified in 6.8 percent. The degenerative changes correlated with age and the number of jumps. Spondylolysis of L5-S1 and L3- L4 segments were observed in 12.2 and 1.4 percent respectively. Progressive spondylolisthesis was found in 2 subjects.

No correlation was found between the severity of radiographic changes and either the prevalence and the severity of low back pain.

The present findings provide a rational for considering repeated sheer stress as an etiology of degenerative changes in the spinal cord, and as a possible contributing factor to the pathogenesis of spondylolysis.

Further study has to be done comparing parachuting instructors to a nonparachuting group, or equivalent physically active individuals, in order to assess the effect of sport-background on the development of degenerative changes.
The Thomas Splint – A Necessary Tool In The Management Of Battlefield Injuries
Authors: Rowlands TK , Clasper J
Published: March 2013

The Thomas splint was developed for the stabilisation of femoral fractures at the end of the nineteenth century, and since the First World War has been extensively used by the British Army. It has been shown to improve the outcome after ballistic fractures of the femur, but recently there have been moves to abandon this device in favour of more modern splints such as the Sager splint©. This is predominately due to the ease of use and smaller size of newer devices, which makes them more suitable for the pre-hospital environment.

However, we present our experience of managing both ballistic and closed femoral injuries using Thomas splints during the recent Gulf Conflict. It is our belief that the Thomas splint is an essential tool in the management of military femoral injuries at role three facilities and must be retained.
Mission Creep: An Analysis Of Accident And Emergency Room Activity In A Military Facility In Bosnia-Herzegovina
Authors: Kenward G , Jain TNM , Nicholson K
Published: March 2013

Objective

To evaluate accident and emergency (A&E) room activity at a Role 3 Multinational Integrated Medical Unit (R3 MIMU) facility in Bosnia- Herzegovina.

Methods

Retrospective analysis of all patients attending the A&E room from 1st October 1999 – 30th September 2002.

Results

1864 casualties are included in the analysis. 52.1% of casualties were Bosnian, 43.8% were military. Mean age of casualties was 35.5 years (SD 18.3), range 1 – 88 years. Traumatic injury was the leading cause of presentation (58.1%). Following treatment 66.7% of all cases were discharged or returned to unit, with 19.8% admitted to a ward area. During the 3 year period there was a 5 fold increase in the number of Bosnian nationals treated, this included 80 children (<13 years).

Conclusion

There has been a dramatic increase in A&E use during the period evaluated, particularly by the local population. The increasing number of locals treated, both adult and child, has the potential to undermine the R3 MIMU mission and increase dependency within the Bosnian population. A balance is needed to ensure the staff and functions of a hospital are maintained whilst preserving the capability to deal with an influx of military casualties.
Cutaneous Myiasis Due To The Tumbu Fly During Operation Keeling
Authors: Parkhouse D
Published: March 2013

Cutaneous myiasis is a temporary infestation of the skin with fly larvae (1). The following is a description of a case of cutaneous myiasis caused by the African Tumbu fly (Cordylobia anthropophaga). The clinical presentation and treatment of this infestation is discussed. A review of the Tumbu fly’s lifecycle with emphasis on the prevention of the disease in the operational environment is also described.
Handheld Ultrasound Diagnosis Of Extremity Fractures
Authors: Brooks A , Price V , Simms M , Ward N , Hand C
Published: March 2013

Hand portable ultrasound has been validated in trauma patients using the FAST technique. The machine’s light and rugged design make it suitable for military deployment and they have been successfully used on deployments in Kosovo, Afghanistan and Iraq. Ultrasound is widely accepted in the diagnosis of abdominal and thoracic trauma, however, little work exists on its use in extremity trauma. Although the diagnosis of fractures usually relies on X-ray this may not be readily available at Role 1 or 2. We successfully identified long bone fractures in three patients using hand portable ultrasound during Operation Telic. The technique and ultrasound findings are described and the current literature on this technique is reviewed.
A Study Into Commanders’ Understanding Of, And Attitudes To, Stress And Stress-Related Problems
Authors: Cawkill P
Published: March 2013

Objectives

To undertake a tri-Service questionnaire survey to examine the commanders’ understanding of, and attitudes to, stress and stress-related problems.

Methods

A questionnaire was designed to elicit information on: Personal experience of stress and stress-related problems; Stress education; Pre-deployments briefings; and Post-incident stress debriefing. A total of 9,020 questionnaires were distributed between the three Services based on their proportional manning contribution to the Armed Forces as a whole. The population sampled ranged in rank from Corporal/Leading Rate up to, and including, Colonel/Captain RN/Group Captain (ranks below Leading Rate/Corporal were excluded because of their lack of command experience). The overall response rate was 55.8%. The study was carried out between September and December 2001 (i.e. pre-OP TELIC).

Results

Chronic work-based stressors were seen as most stressful when compared with family and health stressors. Most respondents accepted that stress and stress-related problems exist, but were reluctant to disclose their own stressrelated problems or seek help for fear that it might be detrimental both personally and professionally. There was found to be little support from peers or commanders. Little stress training was provided during recruit training, there were gaps in pre-deployment briefings and little in the way of post-deployment stress support.

Conclusions

Some of the more negative findings could have implications in terms of seeking help for stress-related problems at an early stage, which is counterproductive to the military’s genuine attempts to foster the psychological welfare of its employees. Some concerns could be alleviated by better and more timely stress education, preferably early on in a commander’s career, so that positive attitudes to stress and stressrelated problems can be formed and any negative attitudes changed, thereby bringing about a change in organisational culture in relation to stress. Some of the study’s concerns were addressed by the Operational Health Strategic Surveillance Committee which advised on operational health aspects of OP TELIC.
Anaesthetics
Authors: Parkhouse DAFH
Published: March 2013

Anaesthesia, like all other medical specialities continues to advance, with improvements in the agents used and techniques employed in order to minimise adverse effects to the patient. This review examines some of these advances and looks forward to what the future might hold in other areas. As well as purely technical advances, other facets of anaesthetic service provision are reviewed, paying particular attention to how to provide a high quality service within the constraints of current working time legislation and revalidation.
Reducing Medical Downgrading In A High Readiness Royal Marine Unit
Authors: Hayton J
Published: March 2013

Objective

This 3 year retrospective observational study aims to determine the diagnoses causing medical downgrading in a high readiness Royal Marine Commando unit, and to direct future investment to reduce numbers downgraded.

Methods

Medical and administrative records were used to ascertain diagnoses, aetiology, time downgraded, and whether men returned to full duties.

Results

4.4% of unit strength was lost through medical downgrading. 43% was due to soft tissue lower limb injuries, of which 41% was due to anterior knee pain syndrome. Low back pain accounts for 24% of the total. Median length of downgrading episodes was 3 months (range 1-40 months). Low back pain and lower limb soft tissue related episodes were longer (median 9 months p= 0.001, and 10 months p=0.003 respectively). Fractures (median 2 months p < 0.001) and general surgical problems (median 2 months p=0.013) were shorter than the overall mean. Orthopaedic conditions related to overuse had longer periods of downgrading (median 6 months) compared to trauma (median 3 months p = 0.01). 9.3% of completed episodes of downgrading resulted in a medical discharge and 1.9% in a permanently reduced medical category.

Conclusions

Conditions that respond rapidly to secondary care interventions have shorter episodes of downgrading compared to overuse conditions. Therefore, prevention and improved rehabilitation facilities are likely to be more effective than further secondary care investment in reducing medical downgrading. More timely use of permanent medical downgrading and medical discharge could reduce temporary downgrading by 20%.
Orthopaedics
Authors: Bird J H
Published: March 2013

Orthopaedic surgery is a large and expanding speciality. There are approximately five million clinic attendances each year in this country and musculo-skeletal complaints are the commonest presentation in General Practice. This review examines three key areas within orthopaedics, fracture management, sports medicine and the new subspeciality of minimally invasive orthopaedics and highlights areas of recent advancement, significant research and ongoing debate.
The Role Of The Physician In Modern Military Operations: 12 Months Experience In Southern Iraq
Authors: Grainge C , Heber M
Published: March 2013

Objectives

To examine the profile of medical morbidity and the role of the physician in modern conflict.

Methods

Retrospective survey of admission records at a British Military Field Hospital on operational duty in Southern Iraq.

Results

62.5% of 4870 admissions to the Field Hospital in Shaibah during the first 12 months of military operations in Iraq were under the care of physicians. Of these 1531 (31.4%) were due to diarrhoea and vomiting (D&V) and 764 (15.7%) due to heat illness. The incidence of heat illness rose with ambient temperature, but soldiers were more likely to be admitted with heat illness shortly after arrival in theatre than when fully acclimatised. There was also a steady flow of admissions with a broad spectrum of medical pathology requiring the clinical skills of a general physician.

Conclusions

A general physician is a necessary part of the clinical team in modern conflict. The incidence of D&V and of heat illness on military operations remains high. Planners for any operation in tropical climates should take this into consideration and put preventative measures into place early.
Incidence Of SLAP Lesions In A Military Population
Authors: Kampa RJ , Clasper J
Published: March 2013

Objectives

SLAP (superior labrum anterior and posterior) lesions are a recognised cause of shoulder pain and instability. They can occur following a direct blow, biceps traction and compression injuries, and are commonly seen in overhead athletes. Military personnel are physically active and often subjected to trauma. We assessed the incidence of SLAP lesions within a military population presenting with shoulder symptoms.

Methods

A retrospective review, of all shoulder arthroscopies performed by a single surgeon between June 2003 and December 2004 at a district general hospital serving both a military and civilian population, was undertaken. The presentation and incidence of SLAP lesions were recorded for both military and civilian patients.

Results

One hundred and seventy eight arthroscopies were performed on 70 (39.3%) military and 108 (60.7%) civilian patients. The average age was 42.3 (range 17-75), 50 females and 128 males were included. Indications for arthroscopy included pain (75.3%), instability (15.7%), pain and instability (7.9%), or “other symptoms” (1.1%). 39 SLAP lesions (22%) were found and grouped according to the Snyder classification – 20.5% type 1, 69.3% type 2, 5.1% type 3, 5.1% type 4. Patients with a history of trauma or symptoms of instability were more likely to have a SLAP lesion (p<0.0001). The incidence of SLAP lesions in the military patients was 38.6% compared to 11.1% in civilian patients (p<0.0001). After allowing for the increased incidence of trauma and instability in the military, SLAP lesions were still more common in the military patients (p<0.001).

Conclusions

There is a higher than average incidence of SLAP lesions in military patients compared to civilian patients. They tend to present with a history of trauma, as well as symptoms of pain and instability. Given the high incidence in military personnel, this diagnosis should be considered in military patients presenting with shoulder symptoms, and there should be a low threshold for shoulder arthroscopy.
Two Cases Of Variant Creutzfeldt-Jakob Disease (vCJD) Referred To The Department Of Community Mental Health, Aldershot Garrison In 2003
Authors: Wickenden PD
Published: March 2013

In the year 2003 the Department of Community Mental Health (DCMH) at Aldershot Garrison received referrals of two soldiers, a sergeant and a lance corporal, who presented with a complex picture of neurological and psychiatric symptoms. Both had been investigated very thoroughly by neurologists who, owing to the mainly negative results of their investigations, were unable to make a diagnosis. Of the two patients one had also been assessed as a psychiatric in-patient in a civilian hospital and had been referred to the Aldershot DCMH for continuing care. The other had been transferred, after investigations, to the Defence Services Medical Rehabilitation Centre (DSMRC) at Headley Court but, failing to make progress, was also referred for psychiatric assessment. Both patients were obviously unwell but the nature of their illnesses remained obscure. Within a few months both had died and the diagnosis of one of the human transmissible spongiform encaphalopathies (TSEs), vCJD, was made at autopsy in one of them, but both were registered by the National CJD Surveillance Unit (3) with a diagnosis of vCJD. The circumstances were so unusual and prompted the writing of this paper by one of the psychiatrists involved.
The House Advancement Anoplasty for Treatment of Anal Disorders.
Authors: Owen Harriet A. , Edwards David P. , Khosraviani Kourosh , Phillips Robin K.S.
Published: March 2013

Objectives

Anal advancement flaps treat a variety of anal disorders. In recent years the “House” advancement flap has been used with good success, the term referring to the shape of the flap used. It is simple with few shortcomings. We reviewed a single centre’s experience of this procedure.

Methods

All patients who underwent a house advancement flap between 1996 and 2001 were identified. The case notes were examined and data collected on indication for surgery, complications, follow-up and outcome.

Results

Thirteen consecutive patients were identified, mean age of 44 years. Indications for surgery were chronic anal fissure, fistulous disease and post surgical deformity or stenosis of the anal canal. Median follow-up was 37 months (25-84). In 9 patients the flaps healed within 4 weeks. In the remaining 4 patients the flaps healed by secondary intention over a median of 14 weeks (8-20). Postoperative complications occurred in 5 patients (3 donor site separation and 2 flap retraction). Two patients developed recurrence of their original disorder. Eleven patients have relief of pre-operative symptoms with fully healed flaps.

Conclusion

This procedure is simple, easy to construct and robust. It can be performed for a variety of anal disorders with satisfactory results and few complications and should be in every Coloproctologist’s armamentarium.
Psychological Morbidity During The 2002 Deployment To Afghanistan
Authors: Campion BH , Hacker Hughes JGH , Devon M , Fear NT
Published: March 2013

Questionnaires were completed by military personnel on arrival (n=1,696) in Kabul, Afghanistan and then again on departure (n=1,134). Analysis of the 113 personnel who completed both the arrivals and departures questionnaire revealed a lower alcohol use score after deployment (AUDIT mean difference (post-deployment – pre-deployment) = -0.39, 95% confidence interval (Cl) = - 1.25 - +0.47) and no significant change to mental health (GHQ mean difference = 0.55, 95% Cl = –0.07 – +1.17). An increase in psychosomatic symptoms (GHQ A mean difference = 0.22, 95% Cl = –0.03 - +0.47) is considered to result from the adverse conditions, but it is not supported by other mental ill health markers. In conclusion, there appeared to be no negative effect on mental health from deployment to Afghanistan.
Heat Illness on Operation Telic in Summer 2003: The Experience of the Heat Illness Treatment Unit in Northern Kuwait
Authors: Bolton JPG , Gilbert PH , Tamayo C C
Published: March 2013

In the mid-summer months of June and July of 2003 some 6000 British Troops deployed to northern Kuwait to heat acclimatise in preparation for the relief of Forces then deployed in Iraq who had recently fought in Operation Telic. This paper outlines the clinical presentations and primary care management of heat illness as seen at a specialist Heat Illness Unit that had been collocated with the acclimatisation camps. It discusses the limitations within current MOD heat illness guidance and makes general recommendations for future deployments. Whilst it was seen that the perception of risk by senior Commanders and the predeployment preparation was correct, the extreme temperatures seen, averaging 46ºC, still resulted in a heat illness rate of 50/1000 during the first 10-14 days of deployment.
Clinical experience with recombinant activated factor VII in a series of 45 trauma patients
Authors: Felfernig Michael
Published: March 2013

Aim

Haemorrhage control is a major priority in the care of trauma patients in military as in the civilian setting. About 50% of combat deaths are due to fatal bleeding. The aim of this analysis was to assess the efficacy and safety of recombinant activated factor VII (rFVIIa; NovoSeven®, Novo Nordisk A/S, Bagsvaerd, Denmark) when used to treat trauma-related blood loss.

Patients and methods

Forty-five patients aged 5–81 years (mean age 30.5 years) received rFVIIa (mean dose 73.6 μg/kg) for the management of trauma-related bleeding. Trauma was classified as blunt (n = 42) or penetrating (n = 3). The primary outcome measure was reduction of transfusion requirements; improvements in coagulation status post-rFVIIa were also noted.

Results

Haemostatic efficacy was achieved in 43/45 (95.6%) patients following rFVIIa administration, and transfusion requirements (defined as median units of packed red blood cells administered in the 24-hour period following rFVIIa administration) were reduced from 10 to 3 units (P < 0.001). Coagulation status also showed improvement (median values for activated partial thromboplastin time and prothrombin time decreased from 43 to 37 s [P < 0.001] and from 19 to 12 s [P = 0.026], respectively). No safety concerns were raised by the available data.

Conclusions

As this analysis has several limitations that are unavoidable when using global registries to collect and analyse data, our findings are not conclusive. However, these preliminary observations especially in those patients who underwent very early rFVIIa treatment offer further support for the use of rFVIIa in trauma.
Reflections on medical aspects of ISAF IX in Afghanistan
Authors: Bricknell Martin CM
Published: March 2013

This paper is a personal review of my experience as the Medical Adviser in the NATO Headquarters of International Assistance Force (ISAF) in Afghanistan from August 2006 to February 2007. It is in 5 sections, medical plans and operations, clinical issues, supporting the Afghan Security Forces Medical Services, supporting Health Sector Reconstruction and Development and preventive medicine. It concludes with a short summary of personal lessons.
Tetraplegia following cervical spine cord contusion from indirect gunshot injury effects
Authors: Goonewardene SS , Mangat KS , Sargeant ID , Porter Keith , Greaves I
Published: March 2013

We present the case of a 31 year old British soldier who sustained a high energy gunshot injury to the neck with delayed onset tetraplegia. The bullet’s transcervical track was subsequently shown to have had no direct contact with the spinal cord, but four to five minutes after injury the patient developed tetraplegia. Subsequent Magnetic Resonance Imaging confirmed this to be due to contusion of the cervical spinal cord. This case illustrates the high levels of energy potentially transferred to surrounding tissues by the passage of a high available energy projectile, causing significant injury to nearby structures not actually impacted by the missile.
A Realistic Model for Catastrophic External Haemorrhage Training
Authors: Moorhouse I , Thurgood A , Thurgood A , Walker N , Cooper B , Mahoney PF , Hodgetts TJ
Published: March 2013

External haemorrhage is a significant cause of combat morbidity and mortality. UK DMS have introduced topical haemostatic agents (HemCon®, QuikClot®) for use as an adjunct to control catastrophic external haemorrhage. Realistic training in new equipment is essential. A model is described that is simple, reproducible, valid, realistic and currently unique in its opportunity to train soldiers to deal with life-threatening external bleeding, without recourse to live animal training. The model has been used successfully to train UK DMS medics, nurses and doctors in Afghanistan.
Primary Blast Injuries to the Eye: A Review of the Evidence
Authors: Abbotts R , Harrison SE , Cooper GL
Published: March 2013

Objectives

Eye injuries are relatively common following detonations. The majority of these are caused by secondary fragments. Primary blast injury to the eye (from the air-blast alone) has been described historically, but the differentiation of air-blast and fragment aetiologies in the reports is not clear. The aim of this review is to consider the evidence in the literature for true primary blast injury to the eye.

Methods

A literature review using Medline, Pub-med and Web of Knowledge databases.

Conclusions

Overall, there is little conclusive evidence that primary ocular blast injury occurs in survivors of explosions. However, some case reports do surmise its occurrence and it cannot be unequivocally ruled out. If it does occur, it is more likely to be at high overpressures that will produce life-threatening injuries. The development of enhanced blast weapons may result in an increased incidence. At present however, the most severe and damaging threat to the eyes from blast remains the impact of fragments and debris.
Retinal Sequelae of Primary Ocular Blast Injuries
Authors: Chalioulias K , Sim KT , Scott R.
Published: March 2013

Primary ocular blast injury is an uncommon and disputed phenomenon. As personal ballistic protection of the head and torso improves for soldiers, increasing numbers of injuries to the unprotected areas such as the face and eyes may be expected; similarly the increase in the use of improvised explosive devices by insurgent terrorists in Iraq is increasing the number of primary blast injuries being seen by the Defence Medical Services. We report a rare case of primary blast injury to the eye and briefly discuss the literature on the subject.
The Effectiveness of a Military Pre-Hospital Fluid Infusion Strategy
Authors: O’Meara Matthew , Wood P , Thurgood A , Porter K
Published: March 2013

We performed a study to assess the effectiveness of a fluid infusion strategy currently used in the military pre-hospital environment using the patient’s own body weight as an infusion device. Thirteen healthy volunteers were cannulated and 0.9% sodium chloride infused over a period of ten minutes. The volumes infused were measured and flow rates derived. A mean flow rate of 40ml per minute was seen through an 18g cannula. This strategy generates reasonable flow rates, but whether this is sufficient to the clinical aim of fluid resuscitation in pre-hospital settings is unknown.
The Management of Difficult Direct Laryngoscopy and Intubation in a Field Hospital: An Alternative to Fibreoptic Endoscopy
Authors: Tong JL
Published: March 2013

Fibreoptic endoscopy and intubation continues to be recommended in guidelines for the management of difficult airways. Since fibrescopes are unavailable within United Kingdom field hospitals, an alternative is needed. The Airtraq optical laryngoscope is a versatile, inexpensive, single-use option, which could readily fill this void. It is easy to use and provides a full view of the glottis when direct laryngoscopy has failed. Its introduction will reinforce existing difficult airway equipment and simplify the management of ‘can ventilate - can’t intubate’ patients.
Cerebral Sparganosis Presenting as Grand Mal Epilepsy
Authors: Walker P , Cooper NK , Brandis A
Published: March 2013

A rare case of cerebral sparganosis is described. This is an uncommon condition particularly in Europe. It is most frequently seen in SE Asia but may be found anywhere in the world. The life cycle of the causative organism is described and contrasted with the principal differential diagnosis of parasitic inflammatory lesions of the brain, Taenia solium, the causative organism of cysticercosis. The treatment of cerebral sparganosis is surgical and diagnosis is most commonly made at the time of pathological examination. The importance of pre-surgical diagnosis is stressed as the treatment of the cysticercosis is pharmacological.
The Operational Emergency Department Attendance Register (OPEDAR): A New Epidemiological Tool
Authors: Russell R , Hodgetts T , Ollerton J , Massetti P , Skeet J , Bray I , Harrison K
Published: March 2013

Aim

To determine the number, status and nature of emergency department attendances to deployed field hospitals.

Population

All attendances to the emergency department (ED) of deployed field hospitals in support of Operation TELIC (Iraq) from initial entry war fighting to enduring operations.

Methods

Analysis of hand written and electronic registers ED attendance registers and validation with four other data sources.

Results

Validation of data held on OpEDAR against 4 other data sources shows that OpEDAR is accurate, but that accuracy can be further improved. 26,746 ED attendances recorded on OP TELIC from 19 March 2003 to 11 November 2006. 21,112 (78.9%) were UK military. Overall, 43.5% were admitted from ED. Attendances peaked during TELIC phases 2 (422.9 per 1,000 troops deployed), but have settled to around 200 per 1,000 troops deployed in the more recent phases. Ophthalmology rates peaked in TELIC 2 to 20.72 per 1,000 and have since reduced to a consistent 10 to 15 per 1,000. This suggests that preventative measures introduced for eye injury are incompletely effective or incompletely utilised.

Conclusions

OpEDAR is a clinical tool to inform manning, equipment and training requirements for enduring and new operations, focused on the requirements of the emergency department. Multivariate quality control models applied in industry could be applied to OpEDAR to produce a dynamic epidemiological tool that identifies emerging case clusters and facilitates deployed commanders to take preventative action.
Tourniquet Use in Combat Trauma: UK Military Experience
Authors: Brodie S , Hodgetts Timothy J , Ollerton Jo , McLeod Judith , Lambert Paul , Mahoney Peter
Published: March 2013

Aim

To determine the prevalence of tourniquet use in combat trauma, the contribution to lives saved and the complications of their use in this environment.

Population

All casualties treated at UK field hospital facilities in Iraq and Afghanistan and meeting criteria for entry into UK Joint Theatre Trauma Registry (JTTR) from 04 Feb 03 to 30 Sep 07.

Methods

Cases were identified from UK JTTR. Casualties from Permanent Joint Overseas Bases (PJOBs) were excluded. ISS, NISS, TRISS and ASCOT were calculated automatically within JTTR from AIS 2005 (Military) codes.

Results

1375 patients met UK JTTR entry criteria for the period specified (excluding PJOBs). 70/1375 patients (5.1%) were treated with one or more tourniquets (total 107 tourniquet applications). 61/70 (87%) survived their injuries. 17/70 (24%) patients had 2 or more tourniquets applied. 64/70 patients received a tourniquet after April 2006, when tourniquets were introduced as an individual first aid item. 43/70 (61%) patients were UK military.

Conclusions

ISS and TRISS are poorly representative of injury severity and outcome for combat trauma involving isolated multiple limb injuries and cannot be used to discriminate whether a tourniquet is life-saving. The presence of severe isolated limb injuries, profound hypovolaemic shock and the requirement for massive transfusion reasonably identifies a cohort where the use of one or more tourniquets pre-hospital to control external bleeding can be said to be life-saving.
Forward Trauma Surgery in Afghanistan: Lessons Learnt on the Modern Asymmetric Battlefield
Authors: Tai N , Hill P , Kay A , Parker Paul
Published: March 2013

The deployment of 16 Air Assault Brigade to Helmand Province, Afghanistan in April-October 2006 was supported by a two -surgeon Field Surgical Team (FST) embedded within a 25 bed medical facility. We report the summative operative experience of the FST in order to analyse workload, case-mix and outline future training requirements. Within this period, 138 patients underwent 255 theatre episodes and 322 surgical procedures. 106 of the 138 patients requiring surgery were battle-injured. Surgical procedures undertaken involved wound excision (95), major amputation (9), laparotomy (9), application of externalfixation/ skeletal traction (6), thoracotomy (4), plaster application (6), dural repair (2), and one tracheostomy with 13 other procedures. Procedures undertaken at subsequent surgery included delayed primary closure (65), split skin graft (7), wound excision (5), tendon repair (3) and 32 others. Complications included two patients with delayed reactionary haemorrhage / post-surgical bleeding requiring re-operation. There was one in-hospital death. Thirty-two patients underwent surgery to treat disease or non-battle injury (DNBI), including 9 patients with major burns who required 26 procedures for burn excision and primary skin grafting. Many of the operations required the deployed team to operate outside of their normal NHS comfort zone. The experiences and lessons learnt and re-learnt by this surgical team should be part of our institutional memory.
Combat-Related Disorders: A Persistent Chimera
Authors: Alexander David A , Klein S
Published: March 2013

Whilst there may be some individuals who genuinely enjoy combat, for most troops it represents many emotional challenges, such as, overcoming fear and being witness to death, suffering and mutilation, as well as having to tolerate extremes of physical discomfort.

At present we lack sufficiently valid and reliable methods of screening out those personnel particularly vulnerable to adverse reactions to these challenges. The authorities should aim to provide good training, an appreciative milieu, and a working climate in which those with genuine psychopathology feel confident to admit this, without censure and stigma, and to have access to evidence-based treatments.

We should also remember that military life offers much to many men and women, and that surviving physically and psychologically the unavoidable brutalities of combat can often leave a legacy of positive outcomes. We must avoid becoming preoccupied with risk and psychopathology.
The Operational Mental Health Consequences of Deployment to Iraq For UK Forces
Authors: Jones N , Greenberg N , Fear N T , Earnshaw M , Mcallister P , Reid G , Wessely S
Published: March 2013

UK Forces are currently engaged in high tempo, high intensity operations in both Iraq and Afghanistan. Concern has been raised about the impact of current operations upon the mental health of Service personnel. Using data gathered from deployed Field Mental Health Teams, a random sample of UK based non-deployed Community Mental Health Teams and services dedicated to mobilising, de-mobilising and to de-mobilised Reserve Forces, this paper explores the current mental health burden for UK Forces. At present, operationally related psychological disorders do not appear to be a substantial concern for Regular Forces, although for the minority that suffer such problems they are both distressing and of occupational relevance. Proportionately there are more mobilised Reserve Forces seeking help for mental health problems than Regular Forces on operations, but the overall burden that they currently place upon the Defence Mental Health Services is small. There is at present no evidence of an epidemic of mental health problems amongst either Regular or Reserve Forces veterans of the Op TELIC deployment, however, this may change in the future given the evolving nature and fluctuating intensity of operational activity.
Hugh Cairns – Neurosurgical Innovator
Authors: Walker N M
Published: March 2013

Following in the footsteps of Victor Horsley, the ‘father of British neurosurgery’, Hugh Cairns continued the tradition of great neurosurgeons associated with the Royal Army Medical Corps. He was a central figure in the acceptance of neurosurgery as a specialty in its own right in Britain, was instrumental in the foundation of Oxford University Medical School, and can legitimately claim to have significantly improved mortality figures in neurosurgical casualties in the Second World War. He was also the driving force in the acceptance of crash helmets for motorcyclists, which have substantially reduced the mortality rates of motorcyclists in those countries in which they have been introduced.
Retrospective Analysis of the Ethnic Origins of Male British Army Soldiers with Peripheral Cold Weather Injury
Authors: Burgess John E , Macfarlane F
Published: March 2013

Objectives

To determine if African Americans, Pacific Islanders and Gurkhas have a different incidence and severity of peripheral cold injury when compared to Caucasians in the British Army.

Method

The design was a retrospective analysis of those British male army personnel aged over 18 assessed at the Institute of Naval Medicine Cold Injury Clinic. The participants were 311 patients assessed on first attendance at the UK Institute of Naval Medicine.

Results

After excluding those classed as normal, African Americans had a relative incidence of 30.36 (95% CI 25.82 – 35.70) when compared to Caucasians; Pacific Islanders a relative incidence of 2.58 (CI 1.24 – 5.38), again against Caucasians. Being of Gurkha ethnicity proved protective, with no abnormal cases found on assessment. The African Americans were more severely affected than Caucasians, with mean scores of 5.39 (SD 1.767) against 4.24 (SD 1.994) for Caucasians. The severity of Pacific Islanders were similar to Caucasians. The ages of African Americans, Pacific Islander and Caucasians had similar means of 26.05, 26.30 and 26.68 respectively, but with a broader age range for Caucasians; SDs 3.428, 2.958 and 7.735.

Conclusion

Young male African Americans in the British Army are at 30 times greater chance of developing peripheral cold injury and are more severely affected than their Caucasian counterparts following similar climatic exposure, using similar clothing and equipment. Pacific Islanders are at a 2.6 times increased risk, while being a Gurkha is protective.
UK Armed Forces Unintentional Firearm Injuries
Authors: Stansfield Tim , Rushforth G
Published: March 2013

Objectives

To report on the incidence of unintentional firearm discharge and injury across the UK Armed Forces and present several cases of this wounding phenomenon.

Method

Munitions Incidents and Defects (MID) Cell data on UK Military Negligent Discharges and unintentional firearm injuries from 01 Jan 03 to 31 Dec 07 was categorised according to cause of injury, wound, service affiliation, incident context and weapon type. The injuries of three patients are described.

Results

Over the 5 year period there were 1158 Unintentional firearm discharges, forty three (4%) of which resulted in injury. Fifty five military personnel sustained unintentional firearm injuries during the review period, more than half of which were gunshot wounds and this included one fatality. The Regular Army suffers an average of 7.7 unintentional firearm injuries per 100 000 Regular Army person years.

Conclusion

Unintentional firearm injury is well recognised across the civilian and police sectors worldwide. Despite the recent tempo of high grade training and operations that currently engage UK Armed Forces this form of injury remains uncommon. We hope to facilitate discussion with the chain of command to manage the risk of these injuries.
Chemical, Biological and Radiation Casualties: Critical Care Considerations
Authors: Bland S A
Published: March 2013

A chemical, biological, radiological or nuclear (CBRN) event would require a critical care response from point of exposure to definitive hospital management. Critical care staff should be aware of the potential agents and possible hazard they present to responders. The treatment of CBRN casualties should reflect the conventional incident and casualty management paradigms with additional safety and treatment considerations. Specific agents may require specific airway and respiratory considerations including surrogate ventilation strategies. All critical care staff training should include CBRN awareness and personal protective equipment training. Some staff may benefit from additional training including the recognition and investigation of CBRN casualties as well as their treatment and the equipment available. Critical care departments should also contingency plans for CBRN events including surge capacity.
Medcaps - Do they Work?
Authors: Bulstrode Christopher
Published: March 2013

The objectives of this paper are to lay out for wider discussion the potential advantages and disadvantages of active military units providing medical care for the local population through ad hoc clinics (MEDCAPS). The literature on this subject has been reviewed and the personal experience of MEDCAPS by the author and other doctors in Helmand Province 2007/8 is presented. Although in the published literature, MEDCAPS are almost universally regarded as being good for relations between the military and civilians, the reality on the ground is that they potentially risk the lives of both staff and patients. and may actually contribute little in terms of relieving suffering, or improving relations between military and civilians. The conclusion of this paper is that MEDCAPs at best have a very limited and specific role, but that there will remain a strong desire from staff on the ground to initiate them.
Preliminary Results of the ‘Surgiligtm’ Synthetic Ligament in the Management of Chronic Acromioclavicular Joint Disruption
Authors: Wood TA , Rosell PAE , Clasper JC
Published: March 2013

Background

Chronic instability of the acromioclavicular joint is relatively common and normally occurs following a fall onto the point of the shoulder. Reconstruction of the joint [Weaver-Dunn procedure] using the coracoacromial ligament is often required in service personnel, and a number of methods to augment this repair have been used. Many of these operative methods require a second operation to remove the metalwork, and in addition can be associated with a failure rate of up to 30%. The ‘Surgilig™’ was originally designed for use in the revision of failed Weaver-Dunn procedures. However this study evaluates its use in the primary operation, reinforcing the autologous graft, in an attempt to reduce the failure rate.

Data Collection And Analysis

We prospectively followed up the Modified Weaver Dunn procedures using Surgilig™. The post-operative x-rays were reviewed at six weeks, three months and then six months to assess the radiological success of the procedure. Our patients were discharged at six months.

Results

We have performed this procedure in 11 patients. One of the 11 patients was excluded from the study as the Surgilig™ graft was used in addition to a hook plate. The remaining ten patients have all reached the six-month post-operative time with no incidence of radiological failure of the graft. After six months they were discharged from clinic follow-up as the coracoacromial graft had sufficient strength to no longer rely on the augment for mechanical stability of the joint. All 10 patients had a good clinical and radiological result. One patient even had inadvertent stress/ weight-bearing x-rays taken at six weeks, with no discernable detrimental effect to outcome.

Conclusion

Although a small study, these initial results for primary fixation of acromioclavicular joint disruption with Surgilig™ are extremely encouraging. The results suggest that Surgilig™ should continue to be used in its current role. As patient numbers increase, a follow-up study to evaluate these preliminary findings should be conducted.
Training Tomorrow’ Military Surgeons: Lessons from the Past and Challenges for the Future
Authors: Eardley WGP , Taylor DM , Parker PJ
Published: March 2013

The nature of conflict is evolving, with current warfare being associated with an initial “shock and awe” phase followed by protracted periods of counter-insurgency and peace support missions. As conflict has changed, so have the munitions deployed and the resulting patterns of injury. Improvised Explosive Devices have become the preferred weapon of the insurgent and the resultant explosive and fragmentation injuries are the hallmark of modern military wounding. These injuries pose a significant challenge to deployed medical forces, requiring a well-defined, seamless approach from injury to rehabilitation.

Traditionally, military medical services demonstrate a poor ‘institutional memory’ in the maintenance of combat surgical skills. Numerous publications detail the re-learning of key tenets of war surgery by generations of surgeons deploying onto the field of battle. While the maintenance of military surgical capability in trained surgeons may be addressed through combat surgical courses, concern exists as to the generic competency of those currently in training and their ability to deal with the burden of injury associated with modern conflict.

The training of junior doctors in the United Kingdom and further afield is in a state of flux. New curriculum development, streamlined and run-through training programmes have combined with the legal requirements of the European Working Time Directive to produce a training landscape almost unrecognisable with that of previous years.

This article investigates the development of current military wounding patterns and modern surgical training programmes. It describes processes already in place to address the unique training needs of military surgeons and proposes a framework for enabling appropriate training opportunities in the future.
Blast Mines: Physics, Injury Mechanisms And Vehicle Protection
Authors: Ramasamy Arul , Hill AM , Hepper AE , Bull AMJ , Clasper JC
Published: March 2013

Since World War II, more vehicles have been lost to land mines than all other threats combined. Anti-vehicular (AV) mines are capable of disabling a heavy vehicle, or completely destroying a lighter vehicle. The most common form of AV mine is the blast mine, which uses a large amount of explosive to directly damage the target. In a conventional military setting, landmines are used as a defensive force-multiplier and to restrict the movements of the opposing force. They are relatively cheap to purchase and easy to acquire, hence landmines are also potent weapons in the insurgents’ armamentarium. The stand-off nature of its design has allowed insurgents to cause significant injuries to security forces in current conflicts with little personal risk. As a result, AV mines and improvised explosive devices (IEDs) have become the most common cause of death and injury to Coalition and local security forces operating in Iraq and Afghanistan.

Detonation of an AV mine causes an explosive, exothermic reaction which results in the formation of a shockwave followed by a rapid expansion of gases. The shockwave is mainly reflected by the soil/air interface and fractures the soil cap over the mine. The detonation products then vent through the voids in the soil, resulting in a hollow inverse cone which consists of the detonation gases surrounded by the soil ejecta. It is the combination of the detonation products and soil ejecta that interact with the target vehicle and cause injury to the vehicle occupants.

A number of different strategies are required to mitigate the blast effects of an explosion. Primary blast effects can be reduced by increasing the standoff distance between the seat of the explosion and the crew compartment. Enhancement of armour on the base of the vehicle, as well as improvements in personal protection can prevent penetration of fragments. Mitigating tertiary effects can be achieved by altering the vehicle geometry and structure, increasing vehicle mass, as well as developing new strategies to reduce the transfer of the impulse through the vehicle to the occupants. Protection from thermal injury can be provided by incorporating fire resistant materials into the vehicle and in personal clothing. The challenge for the vehicle designer is the incorporation of these protective measures within an operationally effective platform.
Selective Non-Operative Management of Ballistic Abdominal Solid Organ Injury in the Deployed Military Setting
Authors: Wood AM , Trimble K , Louden MA , Jansen J
Published: March 2013

This article describes the non-operative management of five patients with ballistic abdominal solid organ injuries in a role 2E medical treatment facility. The selective non-operative management of ballistic abdominal solid organ injury is an accepted management strategy in high-volume civilian trauma centres, and appears to be equally safe and effective in the deployedmilitary setting.