bluuebunny/crossref_metadata_2025 huggingface dataset:
Plastic Surgery
Authors: Heppell PSJ
Published: March 2013

The range of casualties treated by the Defence Medical Services in the recent Gulf conflict has reaffirmed the important role of plastic surgery within the military. This review seeks to highlight some areas of recent innovation and improvement within the realms of plastic surgery generally, of which some, such as the introduction of Flammacerium and the availability of skin substitutes, have direct military relevance.
A Field Mental Health Team In The General Support Medical Setting
Authors: McAllister PD , Blair S P R , Philpott Steven
Published: March 2013

The recent conflict in the Gulf saw the large-scale deployment of Field Mental Health Teams (FMHT), in support of 1 UK Division and its constituent brigades. This article describes the activities and findings from a FMHT deployed alongside a General Support Medical Regiment covering the divisional rear area.

The rate of psychiatric casualties was much lower than anticipated, but the expected bias towards less experienced personnel and reservists was noted.

The article covers all stages of the operation from pre-deployment training, reception, staging and onward integration, operations, redeployment and homecoming, describing the core activities of the FMHT at each stage.
Issues In Temperamental Unsuitability Re-Examining Concepts And Current Practice In The British Army
Authors: Deu N , Srinivasan M , Srinivasan P
Published: March 2013

Currently, in the UK military, and particularly in the Army, a significant number of personnel are regularly discharged on the grounds of being assessed as "Temperamentally Unsuitable (TU) for military duties", under Queen’s Regulations (QRs): (Army) 9.414 and 9.434 (1). In the last two years (2001-2003), preliminary figures suggest that approximately 700 serving personnel were recommended for discharge under this category by only four psychiatrists in the south of England. The regulations governing TU have been in existence and essentially unchanged since their development long before the 1960s albeit subject to parliamentary quinquennial review. The Army General and Administrative Instructions (AGAI) (2) standards also remain unchanged over this period. This paper raises questions about the current validity and relevance of existing TU concepts and regulations with suggestions as to what is being proposed in the context of changing roles, technology and advances in the modern armed forces.
Hospitalisation Due To Lyme Disease: Case Series In British Forces Germany
Authors: Baker B C , Croft A M , Winfield C R
Published: March 2013

Lyme disease is a tick-transmitted infection with disabling sequelae and important occupational health implications for a military workforce. It is likely that some military patients with typical clinical signs remain undiagnosed and untreated. Prompt treatment with an antibiotic is essential, besides targeted education on preventing infection through avoiding exposure to tick bites. We describe four British Forces Germany personnel (two serving military personnel, one adult civilian, one child) who during 2002–2003 required hospital inpatient treatment for Lyme disease. The epidemiology, pathogenesis, clinical features, diagnosis and treatment of the disease are discussed.
Extremity Injuries Remain A High Surgical Workload In A Conflict Zone: Experiences Of A British Field Hospital In Iraq, 2003
Authors: Ramalingam T
Published: March 2013

Background

During this conflict 34 Field Hospital, the sole Coalition field hospital located in Iraq, received and treated casualties with a wide range of injuries. Located very close to the front line during the period of combat hostilities, it was potentially going to deal with relatively fewer battle injured extremities.

Method

A retrospective review of battle casualties admitted to the hospital was carried out based on casualty records and operating theatre logbooks. Data was collected for the period between the 26th March and the 8th May, focusing on casualties who had surgery for battle-injured extremities during the conflict.

Results

Sixty eight (55%) of the 124 casualties who underwent surgery did so for battle injuries to extremities. 139 (58%) of all operating theatre episodes and 189 (53%) of all surgical procedures undertaken were for battle-injured extremities. Fourteen major limb amputations were carried out from a total of 87 battle injured limbs that had surgery, giving an amputation rate of sixteen percent (14/87).

Conclusion

The experience at 34 Field Hospital confirms that extremity injuries do confer a high surgical workload in war. Surgical resources should, therefore, be aimed at this and surgical teams deployed to such environments should be well versed in the surgical management of casualties with limb trauma.
The Incidence And Occupational Outcome Of Overuse Anterior Knee Pain During Army Recruit Training
Authors: Wills A K , Ramasamy A , Ewins D J , Etherington J
Published: March 2013

Objectives

To determine the incidence and occupational outcome of overuse anterior knee pain (AKP) in Army recruits undergoing basic training.

Methods

A prospective cohort study of 1008 Army recruits. Recruits underwent the 12-week phase 1 training program. Cases of AKP were captured through self-presentation of pain at a primary care medical centre. All recruits medical records were reviewed on leaving training and any other lower limb injuries were recorded for comparison with the AKP group. Training outcomes in terms of medical discharges (MD) and discharges as of right (DAOR) i.e, voluntary discharge, were recorded along with training days lost (TDL) and whether a recruit had been held back in training (BS).

Results

8.75% (95%CI: 6.93 – 10.57) of recruits reported to the medical centre with AKP. Of these more than half were referred to see a GP and the majority were from patients with no previous history of AKP (91%, 95% CI: 85.2 – 97.5). The median TDL per AKP case was 3 days (IQR: 3-5 days). The AKP group had a significantly higher (p<0.01) MD rate (12.5%) than the lower limb injury group (3.3%; 95% CI diff: 1.1 – 17.2% ) and the baseline rate of all other recruits (2.5%; 95% CI diff: 2.3 – 17.7%). The majority of AKP cases occurred by week 4 (median) of training (IQR: 2.2 – 6.4).

Conclusions

There was a high incidence of AKP, and while the short term prognosis appears relatively good in the majority of cases as reflected in the median TDL, a large minority were medically discharged and held back in training. Further work should examine methods of reducing the disease burden of AKP in the Army, addressing areas such as aetiology, prevention and treatment.
An Observational Study On The Spectrum Of Heat-Related Illness, With A Proposal On Classification
Authors: Day T K , Grimshaw D
Published: March 2013

During operations in subtropical areas over the summer months of 2001 and 2003 the authors audited 80 patients with heat-related illness, with the intention of defining the nature and distribution of the underlying pathophysiology. Haematological, biochemical and clinical data were gathered prospectively and patients allocated to diagnostic categories on the basis of the combination of clinical findings and investigations. Four basic types of heatrelated illness could be distinguished: (1) excessive salt loss with hyponatraemic dehydration, (2) hypokalaemic alkalosis with low serum bicarbonate, (3) haemodilution associated with excessive water intake in stressed individuals, and (4) loss of normal thermoregulation, characterised by high core temperature and paradoxical cessation of sweating. Most of the patients fell clearly into a single distinct category, but there was a degree of overlap. Reduction of extracellular fluid volume was a common central mechanism. Common provoking factors identified were: gastrointestinal upset, history of previous heat intolerance (35%) environmental temperatures exceeding 45°C, short period of acclimatisation (55%), travel, sleep loss, hard physical work especially if directly preceded by a period of sleep, work in confined humid spaces (45%), and lack of additional salt intake. When several of these factors were present together admission rate over one 24-hour period reached 3% of persons at risk per day. Patients are often more ill than they appear. To reduce the incidence of heat illness during future operations the following measures are proposed:

Avoidance of physical exertion during the heat of the day for the first 7-10 days.

Progressive gentle exercise in the early morning or late evening over the same period.

Increase in daily salt intake to 15-20gm for the first 2-3 weeks.

Only sufficient water intake to relieve thirst and to ensure the flow of abundant dilute urine.
“Bomb Explosion On The Nis Express” – Lessons From A Major Incident, Kosovo 16 Feb 2001
Authors: Vassallo D J , Graham P J K , Gupta G , Alempijevic Dj
Published: March 2013

On Friday 16 February 2001, terrorists detonated a bomb under a civilian coach travelling from Nis in Serbia to Gracanica in Kosovo. 10 people were killed at the scene. 13 casualties were treated in the British KFOR hospital (Reynolds Hospital) in Pristina. Another 8 casualties were evacuated to the American KFOR hospital at Camp Bondsteel. The incident provided a unique opportunity for co-operation between British, American, Russian, German and French KFOR hospitals, as well as with Serbian clinicians and forensic pathologists. This article analyses the medical management of this major incident, identifies the lessons to be learned from it, and also provides enough detail for teaching scenarios.
An Unusual Presentation Of Metastatic Testicular Tumour
Authors: Barton S J , Ashdown DA , Ganta S , Wallace Michael
Published: March 2013

We report a unique case of metastatic malignant teratoma from an undescended testis which presented with acute pulmonary embolism. After chemotherapy, the undescended right testicle was resected along with a cord of non-obstructing inferior venal caval tumour which extended into the right atrium with tumour floating free within the atrium at the end of the cord of tumour. The presentation, diagnosis and treatment of testicular tumours is described and the literature pertaining to testicular tumours in military personnel reviewed.
The Management Of Head Injuries On Military Operations
Authors: Anakwe REB
Published: March 2013

The management of head injured patients has recently been reviewed with the development of civilian guidelines for best practice. These are common injuries which often have significant sequelae for patients and costs for health care providers. Evolving civilian standards of care have implications for military medicine which is often practised in challenging environments. Considerable planning and resources are necessary to meet these standards in an operational environment. The current standards and the problems of applying them in an operational theatre are discussed.
A Review Of 10 Years Of Systematic Health Surveillance In The Army
Authors: Tuck JJH , Bricknell MCM
Published: March 2013

Health and morbidity reporting has been an important feature of the historical assessment of military campaigns from times of antiquity. Most of these reports have concentrated on hospital admission rates and mortality. In 1994 the British Army introduced a primary care health surveillance reporting system called J94. This provided the first opportunity for the systematic capture and analysis of morbidity data that allowed the identification of disease trends and the audit of remedial action. In parallel with the developments made by the military in the field of health surveillance, a number of initiatives in the NHS tried to develop real time surveillance systems with differing degrees of success.

This paper reviews the developments made by military and civilian programs, identifies the problems that have been faced, areas where success has been achieved and the issues that will have to be considered as we prepare for the introduction of the next generation of IT based medical information systems into the military.
Management Of Unstable Cervical Spine Injuries In Southern Iraq During OP TELIC
Authors: Bird JH , Luke DP , Ward NJ , Stewart MPM , Templeton PA
Published: March 2013

Introduction

Cervical spine fractures and dislocations are uncommon injuries that can have serious neurological consequences. These injuries require adequate stabilisation to prevent further spinal cord injury during transfer between hospitals. Evacuation often requires a combination of road ambulance, helicopter and fixed wing aircraft from military hospitals. This paper outlines the neck injuries sustained during Op Telic and discusses the need for Halo vests to be available at Role 3.

Methodology

The MND(SE) Hospital databases were used to identify all casualties admitted with either a “Cervical” or “Neck” injury. The databases covered the period from 24 March 2003 until 15 April 2004. The diagnoses were categorised into minor and serious cervical spine injuries. We defined a serious cervical spine injury as either a fracture or dislocation. We looked at the discharge letters of all casualties evacuated to a Role 4 hospital to confirm whether the casualties had serious cervical spine injuries.

Results

Forty seven casualties were admitted and all were British except three, two Iraqi civilians and one US soldier. Thirty three casualties were returned to their unit for duty, or discharged at the airhead on return to the UK. Fourteen casualties required hospital treatment. There were five serious cervical spine injuries over the study period which included one Hangman’s fracture of C2, one flexion compression injury of C5, one flexion compression injury of C7, one unifacetal dislocation and one bifacetal dislocation.

Conclusions

Five casualties were treated at MND(SE) Hospital for serious injuries to the cervical spine. Two patients were transferred without Halo stabilisation after failing to obtain halos in Iraq. One casualty was kept until a Halo was flown out from the UK.

Recommendations

All unstable cervical spine fractures should be stabilised with a Halo Vest prior to transfer from Role 3. Halo Rings and Vests should be available at Role 3 facilities.
Obstetrics And Gynaecology
Authors: Allen JAC , Selby KF
Published: March 2013

This article outlines some recent advances in both obstetrics and gynaecology. In obstetrics, the new screening tests for Down’s syndrome and the introduction of computer analysis of the fetal ECG are discussed. Cervical screening and the role of human papilloma virus detection is examined and advances in the non-surgical management of menorrhaghia and improvements in the management of urinary stress incontinence are also reviewed.
Medium-Fidelity Medical Simulators: Use in a Pre-Hospital, Operational, Military Environment
Authors: Morrison JJ , Forbes K , Woolrich-Burt L , Russell R , Mahoney PF
Published: March 2013

On Operation Telic 6, the UK Med Group consisting of 3 Close Support Medical Regiment and 205 Field Hospital (Volunteers) deployed to providemedical support to coalition forces in Iraq. Personnel were drawn from Regular and Territorial Units, plus additional medical support from Armies of the Czech Republic and Denmark. The efficient delivery of operational emergency medical care hinged upon the successful integration of personnel from these units. We report on the use of a medium-fidelity simulator, in a pre-hospital and hospital environment over a three month period on an operational tour. In conducting 42 exercises (12 of which commenced in a pre-hospital environment), we have demonstrated the feasibility of the system in rehearsing the management of the major trauma patient. This training was used to enhance teamwork, identify system deficiencies and practise solutions in a safe environment. This paper discusses our experiences in relation to the current literature on this expanding area of trauma training.
Traumatic Variation of Popliteal Artery Entrapment Syndrome.
Authors: Guthrie H C , Hatrick A , Gerrard D J
Published: March 2013

Popliteal artery entrapment syndrome is a well recognised sequelae of anatomical variation in the origin of the medial head of gastrocnemius. It classically presents with distal ischaemia from progressive intimal fibrosis and eventual thrombosis. We present a unique case of acute lower limb ischaemia precipitated by trauma in a young man with undiagnosed popliteal artery entrapment. In this case sudden stress of the lower limb resulted in tearing of the tunica intima of the entrapped artery and exposure of the subendothelium with subsequent thrombus, distal embolisation and acute ischaemia. Successful limb salvage was achieved through endovascular thrombolysis and arterial reconstruction.
Damage Control Surgery and Casualty evacuation:Techniques for Surgeons, Lessons for Military Medical Planners
Authors: Parker Paul J
Published: March 2013

Damage Control Surgery (DCS) is a three-phase team-based approach to maximal injury penetrating abdominal trauma. In Phase I, the hypothermic, coagulopathic, acidotic, hypotensive casualty undergoes a proactively planned one-hour time limited laparotomy by an appropriately trained surgical trauma team. In phase II – physiological stabilization takes place in the Intensive Care Unit. In phase III – definitive repair occurs. DCS is extremely resource intensive but will save lives on the battlefield. A military DCS patient will perioperatively require fourteen units of blood and seven units of fresh frozen plasma - half the blood stock of a light-scaled FST. Two DCS patients will in one day, exhaust this FSTs oxygen supply. We know that hypothermic patients with an iliac vascular injury (initial core temp <34°C) suffer four-fold increases in their mortality, yet we cannot heat our tents above 20°C during a mild British winter. Our primary casualty retrieval is excessively slow. A simple casevac request has to go to too much ‘middlemanagement’ before a flight decision is made. In Vietnam, wounded soldiers arrived in hospital within twenty-five minutes of injury. In Iraq in 2005, that figure is over one hundred and ten minutes. We use support or anti-tank helicopters that are re-roled on an adhoc basis for the critical care and transport of our sickest patients. We still do not have a dedicated all-weather military helicopter evacuation fleet despite significant evidence that intensive care unit level military evacuation is safe and eminently achievable in both in the primary and secondary care setting. Should we not be asking why?
The Role of Local Steroid Injections in an Operational Field Hospital Setting
Authors: Ramasamy A , Shah RR , Bhullar TPS , Warnock F , Pitman T
Published: March 2013

Objectives

To assess the safety and effectiveness of administering local steroid injections in an operational field hospital environment.

Method

A prospective study of patients presenting to the physiotherapy department at the British Military Hospital (BMH) Shaibah, Iraq was undertaken from July 2006 – September 2006. Patients with a condition amenable to local steroid injection and who had not improved with conservative therapy were considered for the study. They then underwent local injection with steroid and local anaesthetic.

Results

During this period 12 patients were identified that fitted the criteria for local steroid injection. This represented 7% (12/179) of patients who were seen by the physiotherapy department in either an in or out-patient setting. All patients were injected with local anaesthetic and steroid injection with a single dose of intravenous antibiotic as antimicrobial cover. 10/12 (83.3%) were able to return to their unitwithin this theatre of operation. The only complication was one case of post injection flare of pain, which settled after 48 hours.

Conclusion

The use of local steroid injection, as an adjunct to physical therapy, can enable service personnel to remain in the theatre of operations. These patientsmay have otherwise required aero medical evacuation. We consider the use of a local steroid injection to be a safe and effective intervention in certain patients where conservative measures alone do not work. This study highlights the safety of using steroid injections in an operational field hospital setting. Further large scale studies may help corroborate this conclusion.
Posterior Fracture Dislocation of the Hip from a Warrior Turret Injury
Authors: Ramasamy A , Bhullar TPS
Published: March 2013

Fracture of the femoral head after hip dislocation is a relatively rare injury and is often associated with a poor functional outcome. Most result from high impact motor vehicle accidents. We report the case of a soldier who trapped his foot in a traversing Warrior turret and suffered a severe abduction injury to his hip. He sustained a Pipkin Type I fracture-dislocation of the hip not amenable to closed reduction and required transfer to the American Hospital in Baghdad where he underwent emergency open reduction and internal fixation of the fracture. This case report illustrates an unusual mechanism of injury resulting in a posterior fracture-dislocation and reviews the literature pertaining to the presentation, treatment and prognosis of this condition.
Various Contract Settings and their Impact on the Cost of Medical Services
Authors: Magnezi Racheli , Dankner R , Kedem R , Reuveni H
Published: March 2013

Objectives

This study analyzes the effect of outsourcing healthcare on career soldiers in the Israel Defense Forces (IDF) in different settings, so as to develop a model for predicting per capita medical costs.

Methods

Demographic information and data on healthcare utilization and costs were gathered from three computerized billing database systems: The IDF Medical Corps; a civilian hospital; and a healthcare fund, providing services to 3,746; 3,971; and 6,400 career soldiers, respectively. Visits to primary care physicians and specialists, laboratory and imaging exams, number of sick-leave days, and hospitalization days, were totaled for men and women separately for each type of clinic. A uniform cost was assigned to each type of treatment to create an average annual per capita cost for medical services of career soldiers.

Results

Significantly more visits were recorded to primary care physician and to specialists, as well as imaging examinations by Leumit Healthcare Services (LHS), than visits and tests in hospitals or in military clinics (p<0.001). The number of referrals to emergency rooms and sick-leave days were lowest in the LHS as compared to the hospital and military clinics (p<0.001). The medical cost per capita/year was lowest in LHS as well.

Conclusions

Outsourcing primary care for career soldiers to a civilian healthcare fund represents a major cost effective change, lowest consumption and lower cost of medical care. Co-ayment should be integrated into every agreement with the medical corps.
A review of one year of British Armed Forces mental health hospital admissions
Authors: Finnegan A , Finnegan S , Gamble D
Published: March 2013

Objectives

The paper provides a review of one year of military Mental Health (MH) hospital admissions. This includes an exploration into demographic trends, differences in clinical opinion and how information gained is used to improve the service and ensure appropriate, cost effective care in the optimum environment.

Methods

The sample group is entitled military MH hospital admissions from 1 April 2005 to 31 March 2006. Data was collected on questionnaires with SPSS used for the management and analysis of the quantitative data, with the information exposed to descriptive and inferential statistical analysis.

Results

There were 344 admissions. The paper contains a detailed review of a number of variables. Depression was the most common diagnosis resulting in 112 (33%) hospital admissions and Post Traumatic Stress Disorder accounted for 23 (7%). There were statistically significant differences that may be attributable to gender with more women admitted with depression and more men with alcohol related disorders. The average length of stay was 21 days, with 48% of patients discharged within 3 weeks. 45% of all returns included significant events reporting that highlighted written evidence of good and poor practice.

Conclusion

This study is part of an extensive monitoring programme of military MH hospital admissions. Depression is the most common MH problem leading to hospital admission. The results indicate that Service-personnel have access to a highly responsive service that provides brief assessment and treatment within a safe therapeutic environment. 45% of returns included significant event information that resulted in policy changes, leading to improved patient care and a better interface with the NHS. Bench-marking, both internally between military Departments of Community Mental Health and externally have improved visibility and self awareness leading to better GP induction programmes, PHC educational seminars and the establishment of MH web-pages. The Armed Forces need an effective MH service that is accessible, readily available, non-stigmatised and which positively advocates a duty of care. The results highlight the importance of further studies regarding depression to ensure that the Armed Forces are in a better position to maximise the use of MH resources.
Roles for International Military Medical Services in Stability Operations (Reconstruction and Development)
Authors: Bricknell MCM , Gadd RDM
Published: March 2013

This is the last in a series of three papers that provide a discussion on the wider roles of military medical forces in stability operations. It examines the framework for civil-military co-operation in humanitarian operations and complex emergencies. It then introduces the non-military components of ‘stability’ operations and examines the military role in reconstruction and development. The paper examines the potential capabilities of military medical services in providing medical support for non-military populations, Village Medical Outreach Programmes and medical infrastructure projects.
Do Military Uniform and Rank Impact on the Therapeutic Relationship between Military Mental Health Clients and Clinicians?
Authors: Wilson MM , McAllister PD , Hacker Hughes Jamie , Fear NT
Published: March 2013

Objective

To measure the perceptions of military staff of the impact of wearing military uniform on the therapeutic relationship with mental health clients.

Method

A brief questionnaire was distributed to all military clinicians in Departments of Community Mental Health to measure their attitudes.

Results

There was a 67.9% (n=70) response rate regarding the impact of uniform on the therapeutic relationship. 20% of responses were positive, 31% negative, 37% mixed and 12% gave no answer.

Conclusion

There was no clear pre-existing literature on this issue. Overall, the wearing of uniform appeared to be perceived positively positive. There is a need to assess clients’ points of view in future studies.
An Evaluation of the Medical Training Application Service as Experienced by Defence Medical Service Medical Officers
Authors: Owen J P
Published: March 2013

Objectives

In 2007 Defence Medical Service (DMS) Medical Officers (MOs) applying to train within hospital based specialities were selected using the Medical Training Application Service (MTAS). Recognising the problems being reported about MTAS, the Defence Postgraduate Medical Deanery (DPMD) conducted an evaluation in order to assess whether DMS MOs had also experienced problems with the MTAS process.

Methods

DMS MO applicants were sent an email questionnaire, requesting both graded (Likert scale) and narrative responses, to gauge their opinion about the application service. The questionnaire covered the technical aspects of the process, the support available and the ability to demonstrate appropriate knowledge and skills.

Results

Only 42 responses (32%) were received. However, having considered areas of potential bias, the graded questionnaire results and thematic analysis of the narrative responses showed a clear consensus amongst the applicants in many areas. More than three quarters (78%) of DMS applicants criticised the opportunity to record their abilities and achievements, and 91% recorded that the questions were unable to differentiate between candidates. These views were mirrored in the narrative responses, with more than 130 statements covering five topic areas highlighting areas for improvement. Strong support was recorded for the work and advice provide by DPMD in support of the candidates.

Conclusions

DMS MOs presented very negative opinions of their experiences of MTAS, highlighting their perceptions that they were unable to record their particular skills and experiences and that the questions were unable to discriminate between specialties. Particular difficulties were reported in presenting non-NHS experiences and skills.
The Battle for Goose Green – The RMO’s view
Authors: Hughes SJ
Published: March 2013

By virtue of the Battalion I serve with, I was the first Task Force Doctor on to the Falklands. On Friday the 21st May, 2 Para made an assault beach landing, thankfully unopposed, on San Carlos beach, the RAP was with them.

Introduction

As 2 Para occupied the Sussex Mountains for six days and on Wednesday 2 May, moved off at last light to Camilla Creek House, 5 miles from Darwin. The Battalion laid up in the area of Camilla Creek during 27 May and early the next morning moved out to create history….
A Treatment Algorithm for Mass Heat Casualties
Authors: Bruce ASW , Tunstall C , Boulter MJ , Coneybeare A
Published: March 2013

Although thankfully rare, heat related illness has significant implications for the effective fighting force available to commanders. This is especially pertinent in the current theatres of operations, as previously soldiers have not routinely been subjected to the rigors of operating in hot climates. In addition to Iraq and Afghanistan, various training exercises are undertaken throughout the world where extreme temperatures may be encountered. Individual medical officers may be faced with heat casualties remote from all but the most basic facilities or the number of heat casualties may overwhelm limited resources. We present a simple treatment algorithm that has been used successfully in the treatment of mass heat casualties.
Why Military Personnel Fail to Keep Medical Appointments
Authors: Thornton R , Ballard K
Published: March 2013

Objectives

Failure to keep medical appointments, commonly referred to as ‘Did Not Attend’ (DNA), is a frequent problem in both primary and secondary health care and leads to a waste of valuable resources. Although the reasons for DNA within the general population are well documented, little is known about this behaviour amongst people serving in the armed forces. In this paper we report the findings of a questionnaire-based study investigating the reasons why military personnel fail to keep hospital appointments.

Method

A postal questionnaire asking questions about the reasons for not attending the appointment and how they perceived the condition for which treatment had been sought, were sent to 167 military patients known to have missed appointments in either a hospital outpatient department or regional rehabilitation unit. 162 controls, who attended appointments, were also sent a questionnaire asking them about factors leading to their appointment and how they perceived the condition that they attended the appointment for. Illness perception was measured using a previously validated Illness perception Questionnaire (IPQ-R). The controls were matched by rank, gender and corps.

Results

The overall response rate was 51.5%, with 46% response in the DNA group and 55% in the controls.

A previous history of hospital DNA (though not DNA in primary care) and attempting to change the appointment date were associated with DNA (p=0.01). Those who received a reminder about the appointment were less likely to DNA (p=<0.001). Although patients who perceived their condition to be less important were more likely to fail to attend their appointment (p=0.01), illness perception as measured on the IPQ-R, was not associated with appointment attendance.

The most frequent reasons cited for missed appointments were due to administrative problems, with many (38%) respondents being simply unaware that they had an appointment at all or believing that they had cancelled it (14%). Forgetting the appointment (8%) or mixing up the date (21%) were also cited by respondents as reasons for not attending. Only 11% of respondents gave reasons that were specific to a military population, most frequently being on exercise at the time of their appointment.

Demographic differences such as age and gender, and practical factors such as appointment day, distance travelled, method of appointment notification, or type of hospital were not found to be associated with attendance.

Conclusion

The most common reasons for not attending appointments were due to administrative error and an inability amongst patients to recall the correct date of the appointment. Whilst efforts to improve attendance through various reminder systems have been found to be effective in the short term at least, improvements in the efficiency of appointment administration is likely to generate a reduction in DNA and in turn will reduce the wastage of resources.
BATLS/BARTS/BBTLS Training for Swedish Armed Forces Medical Personnel – A Ten Year Retrospective Study
Authors: Lundberg Lars , Molde Å , Dalenius E
Published: March 2013

Objective

The British BATLS/BARTS concept was introduced in Sweden in 1998. Perceived changes within the student group, regarding purposes for taking the course and previous trauma training were the subject of the study.

Methods

Records from all Swedish courses during 1998-2007 were examined and analyzed.

Results

In all, 61 courses with a total of 1254 students were conducted. Among the participants were 295 doctors, 764 nurses, 176 medical orderlies and 19 belonging to other categories. The course has by time become a pre-mission course. Also, a large number of the students now have previous (often civilian) trauma life support training.

Conclusion

When the British BATLS/BARTS concept was introduced in Sweden ten years ago, the general level of trauma training among medical personnel was inadequate for the wartime needs of the Armed Forces. Today, the majority of individuals selected for international service already have previous trauma life support training. This has led to the courses now being aimed mainly at improving their knowledge of the tactical medical skills particular to the environment in which they will serve.
A Case of External Ophthalmomyiasis in a Deployed UK Soldier
Authors: Stacey Mike , Blanch RJ
Published: March 2013

Infestation of the eye by larval fly forms (ophthalmomyiasis) is rarely seen in the Western world. We present the case of a 21 year old British soldier who developed external ophthalmomyiasis during an operational tour of southern Afghanistan. This case report and discussion illustrates the potential for ophthalmomyiasis in personnel deployed to this theatre; the possibility of infestation without an identifiable episode of exposure; the importance of proper assessment and follow-up in order to identify sight-threatening complications; and the balance between optimal patient care and the risks inherent to casualty evacuation demanded by modern day stability operations.
Prolonged Incarceration: Effects on Hostages of Terrorism
Authors: Busuttil Walter
Published: March 2013

Background

In recent years there has been an explosion in the publicity surrounding hostage taking. There have been many well-publicized hostage, prisoner of war and politically motivated incarcerations. Increasingly hostages are being paraded on television and sometimes even films of executions posted on the internet. Hostage taking has usually occurred in countries where there has been political strife and war, especially, in recent years, in Iraq and Afghanistan, most recently involving British Royal Navy Personnel in Iran and a British journalist in Palestine.

Aims

The aim of this paper is to review the adult literature regarding hostage taking with a view to highlighting the most likely psychiatric disorders that can develop during such an experience. This will aid planning and implementation of hostage rehabilitation and family reintegration post release. This paper will help build insight into the experiences and potential clinical presentations of those held hostage under conditions of torture and threat of death. It presents a framework of needs allowing the planning of rehabilitation including how to manage the family and the media.

Conclusions

Further specific research is needed in order to assess the full needs of those released from prolonged incarceration held under threat of death. This will allow better planning for, and delivery of, rehabilitation of those released.
The Mental Health of Veterans
Authors: Murphy D , Iversen A , Greenberg N
Published: March 2013

For the majority service in the Armed Forces is beneficial and, in the main, military veterans have successful lives. However, a minority have a bleaker outlook as a result of on-going ill health and social exclusion. Whilst the media focuses on Post Traumatic Stress Disorder, in reality the most frequent mental health problems for veterans are alcohol problems, depression and anxiety disorders. These difficulties are difficult to manage as veterans, particularly those who are unwell, demonstrate a reticence to seek help for mental health problems. Another issue is that many veterans are now reserve personnel who have been found to be at greater risk of developing mental health problems than their regular counterparts. Steps to improve the knowledge and expertise of primary care services about veteran’s mental health issues and increasing the availability of treatment options are important and are underway.
Collaborative Training with Ambulance Service NHS Trusts
Authors: McBroom R J
Published: March 2013

Creating opportunities for pre-hospital emergency care Army medical staff to maintain their clinical and medical management skills whilst in barracks has always been a challenge for Commanding Officers. In the past there have been informal relationships between some units and Ambulance Trusts; however, these have usually faltered and been seen as unsustainable. Memoranda of Understanding (MoU) between 5 General Support Medical Regiment and the North West and Yorkshire Ambulance Service NHS Trusts, using the Ministry of Defence/Department of Health Concordat as a backdrop, has hopefully created a more formal training relationship which will produce a sustainable collaboration to create training opportunities for both parties. This article highlights the training opportunities available, the factors to consider in planning MoUs and the benefits to be gained.
A Rare Cause of Recurrent Iron Deficiency Anaemia
Authors: Binham John , Arshad I , Evans HJR , Rehman S
Published: March 2013

Gastro intestinal Stromal Tumours (GISTs) are a rare neoplasm of the gastrointestinal tract. They often grow silently and present late when surgical cure is not possible. Chemo and radiotherapy have a very poor success rate. We present a case of successful surgical removal of a gastrointestinal stromal tumour in a patient who presented with GI bleeding and a recurrent microcytic anaemia.
The Civil and Military Medical Response to Natural Disasters
Authors: Dowlen Henry , Nicol E , Mozumder A
Published: March 2013

This article explores the topic of military involvement in disaster response. This was debated during a conference held at the Royal Society of Medicine, through presentations on experiences and procedures within both the military and civilian roles. The conference was run jointly by the Haywood Club Tri-Service Medical Society and the Catastrophes & Conflict Forum of the Royal Society of Medicine on 20th April 2007.

Issues of collaboration and accountability are seen as key themes of disaster response, within which the military can have a role, but which needs to be carefully administered in order to avoid an inappropriate response with an associated political fallout.

This article does not represent the official stance of government or any of the agencies therein.
Hospex and Concepts of Simulation
Authors: Arora S , Sevdalis Nick
Published: March 2013

A conceptual three-level framework is presented for understanding the aims, scope and potential outcomes of simulation in healthcare contexts. At the first level, micro-simulation aims at honing basic technical skills of individual clinicians. At the second level, meso-simulation aims to train clinicians to work more effectively and efficiently as part of a clinical team. At the third level, macro-simulation aims to assess organisational fitness for purpose at large scale. We discuss HOSPEX as an exemplar macro-simulation and argue for needs- and evidence-based implementation of simulation-based training at micro, meso and macro levels.
Which Quality and Outcomes Framework (QOF) Clinical Indicators are Applicable for British Forces Germany Health Service (BFG HS) Primary Care?
Authors: Heuvel HGJ van den , Simpson RG
Published: March 2013

Objectives

To determine which QOF clinical indicators are applicable for BFG HS primary care.

Method

In depth cross-sectional survey of BFG HS general practitioners. Participants were requested to assess all 19 QOF clinical domains (80 clinical indicators) and to indicate to what extent these were applicable for BFG HS (Likert scale 1 – 5). Response rate was documented. Cronbach’s alpha reliability was calculated and a comparison of the mean responses of training and non-training practices was made.

Results

The response rate was 80% (28/35). Cronbach’s alpha was 0.91. The mean score for both training practices and non-training practices was 3.9. Based on the mean score the applicable indicators were (in descending order): Hypothyroidism (mean 4.6, 95% confidence interval 4.5 - 4.8), Hypertension (4.6, 4.5- 4.8), Asthma (4.3, 4.2- 4.5), Diabetes mellitus (4.3, 4.2- 4.3), Obesity (4.1, 4.0- 4.2), Chronic Heart Disease (4.1, 3.9- 4.2), Epilepsy (4.0, 3.9- 4.2) and Smoking (4.0, 3.7- 4.2). Problematic were (descending means): Cancer (3.9, 3.6- 4.2), Stroke and TIA (3.8, 3.7- 4.0), Atrial fibrillation (3.6, 3.3- 3.8), Learning disabilities (3.5, 3.1- 4.0), Chronic kidney disease (3.5, 3.3- 3.8), Chronic Obstructive Pulmonary Disease (3.5, 3.3- 3.7), Mental health (3.5, 3.3- 3.6), Heart failure (3.4, 3.1- 3.7), Depression (3.2, 2.8- 3.5) and Palliative care (3.2, 2.7- 3.6). Not applicable was Dementia (2.4, 2.0- 2.8).

Conclusion

This study shows that several but not all QOF clinical indicators are applicable in BFG HS. Therefore QOF cannot be directly transferred to BFH HS and an adapted quality framework is required.
Phytophotodermatitis after Gardening
Authors: Wild G
Published: March 2013

Phytophotodermatitis, otherwise known as ‘Strimmer’s Rash’ is an unusual cause of a widespread rash. We present a case of phytophotodermatitis, which was initially misdiagnosed as chickenpox; the correct diagnosis was made after further careful history taking and illustrates the importance of taking a thorough history when presented with what appears to be a spot diagnosis.
Exercise Triple Serpent 2008
Authors: McCourt A , Risdall J , Tuck J
Published: March 2013

Exercise Triple Serpent, the Surgeon General’s biennial clinical conference, was held on 24-26 June 08. Several areas of DMS activity were covered during the course of the conference ranging from operations, through research and clinical development to the forthcoming DMS structural change. This paper provides a commentary on the principle themes and presentations.
Patellofemoral Pain Group (PPG) – A Review of the First 100 Patients to Complete the Course at the Regional Rehabilitation Unit Gütersloh
Authors: Harris William J
Published: March 2013

Anterior knee pain syndrome is extremely common in the military and has previously often led to medical discharge. The Patellofemoral Pain Group programme of exercises developed at the Defence Medical Rehabilitation Centre at Headley Court has become the first line treatment strategy for this problem in the military. The introduction of this low level, impact free, progressive exercise programme at the Regional Rehabilitation Unit in Gutersloh has also proved useful, leading to improvements in employability of affected soldiers and reduction in symptoms.
Percutaneous Nephrolithotomy for Removal of a Calcified Intra-Renal Artillery Shell Fragment
Authors: Naeem I , Masood J , Buchholz Noor
Published: March 2013

Residual metallic fragments after intra-abdominal penetrating injuries due to fragments of artillery shells are generally inert, although they may rarely re-activate. The authors present a case where such a fragment presented as a renal stone 17 years after injury. The literature was reviewed and the initial difficulties with the radiological diagnosis, as well as treatment approaches and post-operative findings are discussed in the light of existing reports. An additional challenge arose as the authors working in a tertiary endourology centre attempted to remain as minimally invasive as possible, but were limited by the very nature of the foreign body.
Military Tropical Medicine
Authors: Bailey Mark S , Ellis CJ
Published: March 2013

Tropical diseases remain a significant threat to deployed military personnel as demonstrated by recent outbreaks amongst troops in Sierra Leone, Iraq and Afghanistan. Five cases are presented from military deployments in tropical or sub-tropical areas, which illustrate important diseases and diagnostic principles for military physicians.
Early Treatment with Nebulised Salbutamol Worsens Physiological Measures and Does Not Improve Survival Following Phosgene Induced Acute Lung Injury
Authors: Grainge C , Brown R , Jugg Bronwen , Smith AJ , Mann TM , Jenner J , Rice P , Parkhouse DA
Published: March 2013

Objectives

To examine the effectiveness of nebulised salbutamol in the treatment of phosgene induced acute lung injury.

Method

Using previously validated methods, 12 anaesthetised large white pigs were exposed to phosgene (Ct 1978 ± 8 mg min m-3), established on mechanical ventilation and randomised to treatment with either nebulised salbutamol (2.5mg per dose) or saline control. Treatments were given 1, 5, 9, 13, 17 and 21 hours following phosgene exposure. The animals were followed to 24 hours following phosgene exposure.

Results

Salbutamol treatment had no effect on mortality and had a deleterious effect on arterial oxygenation, shunt fraction and heart rate. There was a reduction in the number of neutrophils from 24.0% ± 4.4 to 12.17% ± 2.1 (p<0.05) in bronchoalveolar lavage, with some small decreases in inflammatory mediators in bronchoalveolar lavage but not in plasma.

Conclusion

Nebulised salbutamol treatment following phosgene induced acute lung injury does not improve survival, and worsens various physiological parameters including arterial oxygen partial pressure and shunt fraction. Salbutamol treatment reduces neutrophil influx into the lung. Its sole use following phosgene exposure is not recommended.
Self Assessment Exercises in Intensive Care Medicine
Authors: Henning J , Hunt PAF
Published: March 2013

Intensive Care Medicine (ICM) is no longer the exclusive preserve of anaesthetists as both emergency medicine and general medicine trainees now also train in this increasingly important speciality. This edition of the JRAMC self assessment question series serves to cover some of the current ‘hot topics’ in ICM and enables readers with experience of ICM to test their knowledge as well as educating junior trainees in relevant subjects that they may be unfamiliar with. Similarly, the Focus On . . . . series of papers elsewhere in this journal demonstrate the increasing importance of ICM in the deployed Field Hospital setting.