bluuebunny/crossref_metadata_2025 huggingface dataset:
Medical Conditions Requiring Intensive Care
Authors: Porter D , Johnston A McD , Henning J
Published: March 2013

Patients who require critical care for internal medical conditions make up a small but significant proportion of those requiring evacuation to the Royal Centre for Defence Medicine in Birmingham, UK. Infectious, autoimmune, neurologic, cardiac and respiratory conditions are all represented. Conditions which preclude military service and which one would not necessarily expect to see in a military hospital are still prevalent in civilian contractors and host nation personnel. With some 250,000 British military personnel based in the UK and overseas individual presentations of rare conditions occur regularly. This article discusses the ITU management of some key conditions. Whilst trauma makes up the majority of the workload in a field Intensive Care Unit, medical admissions happen not infrequently. This article describes some of the most common medical causes for admission and treatment is considered.
Paediatric Intensive Care in the Field Hospital
Authors: Harris CC , McNicholas JJK
Published: March 2013

Our recent experience of paediatric critical care during UK military operations in Afghanistan is discussed alongside consideration of the background to the paediatric critical care service on deployment. We describe the intensive care unit’s capabilities, details of recent paediatric critical care admissions during July to September 2008 and some of the ethical issues arising. Some desirable future developments will be suggested.
Are IVC Filters Required in Combat Support Hospitals?
Authors: Parent Philippe , Trottier VJF , Bennett DR , Charlebois PB , Schieff TD
Published: March 2013

Background

Haemorrhagic shock from traumatic injuries is now often treated using a damage control resuscitation strategy that transfuses packed red blood cells, plasma and platelets in a 1:1:1 ratio, early use of activated recombinant factor VII and transfusion of fresh whole blood. These therapies are aimed at promoting thrombosis in injured vessels. Such patients are at high risk for thrombotic complications and thromboprophylaxis is necessary, but frequently impossible to use in the early phase of care.

Case presentation

We describe the case of an Afghan civilian worker who suffered a vertical shear pelvic fracture with massive bleeding in a pedestrian/truck collision that was treated with a damage control resuscitation strategy, and who later suffered a severe pulmonary embolus. The potential use of a temporary inferior vena cava [IVC] filters is discussed.

Recommendations

Care providers and policy makers must recognize that the increased use of prothrombotic strategies of resuscitation will likely increase the incidence of thrombotic complications in the high risk population of severely injured patients in combat support hospitals. Monitoring the incidence of these complications and development of strategies for prevention and treatment are required to avoid undermining the positive outcomes of damage control resuscitation. These strategies could include supplying combat support hospitals with the equipment and training necessary for placement of temporary IVC filters under fluoroscopic guidance.
Pelvic Ring Injuries in the Military Environment
Authors: Adams S A
Published: March 2013

Haemodynamically unstable patients with mechanically unstable pelvic ring injuries continue to present a challenge to all personnel involved. Road traffic accidents remain a significant cause of soldier morbidity and mortality in peacetime and in war. These pelvic ring disruptions are markers of high-energy transfer injuries and are associated with fatal exsanguinating haemorrhage. Identifying the ring injury and the source of bleeding remains a complex challenge. Early control of instability, both haemodynamic and mechanical is likely to produce the best results. Dealing with these issues in the military environment adds additional stress to this volatile situation. Multidisciplinary practice guidelines have been shown to reduce mortality and should be adopted by all establishments treating these causalities. A well-rehearsed ABC approach with a proactive approach to clot protection and promotion is ideal.
Combat Casualty Care Research at the U.S. Army Institute of Surgical Research
Authors: Baer D , Dubick MA , Wenke JC , Brown KV , McGhee LL , Convertino VA , Cancio LC , Wolf SE , Blackbourne LH
Published: March 2013

The Institute of Surgical Research is the US Army’s lead research laboratory for improving the care of combat casualties. The Institute follows a rigorous process for analyzing patterns of injury and the burden of disease to determine where research can be conducted in order to positively impact care. These analyses led the ISR to focus research on: preventing death frombleeding; developing improved pain control techniques; developing improved vital signs analysis techniques; improving the treatment of extremity injuries; preventing burn injuries on the battlefield; and improving critical care for combat casualties. This process has resulted in numerous improvements in care on the battlefield. Highlights include development, fielding, and efficiency testing of tourniquets and improved dressings for bleeding control. Significant progress has also been made in the resuscitation of combat casualties using blood products instead of crystalloid or colloid solutions. Improvements in pain control include assessments of the effect of perioperative anaesthetics on the development of Post-Traumatic Stress Disorder [PTSD]. Novel vital signs analyses have been successful in identifying promising techniques which may improve the medic’s ability to accurately triage patients. Current research in extremity injuries has focused on optimizing the use of negative pressure wound therapy for contaminated wounds. Burn research has focused on improving personnel protective equipment and implementing continuous renal replacement therapy. This research program is soldier focused and addresses care from self aid and buddy aid through all echelons of care. Many of these advances have been adopted in civilian medical centres as well, benefiting not only the military trauma patient, but also the civilian trauma patient.
Operational Morbidity Analysis: Ophthalmic Presentations During Operation Telic
Authors: Ollerton JE , Hodgetts TJ
Published: March 2013

Aim

This paper analyses all ophthalmic attendances to a deployed emergency department (ED) in Iraq to identify patterns of injury to optimise patient care, plan equipment tables for future operations and emphasise need for prevention of ocular morbidity.

Methods

The Academic Department of Military Emergency Medicine at the Royal Centre for Defence Medicine in Birmingham maintains an electronic database with details on all attendances to the emergency departments deployed on Operations. This Operational Emergency Department Attendance Register (OpEDAR) was searched for all patients with medical classification of Ophthalmology over a 52 month period between 1 March 2003 and 30 June 2007.

Results

During this period 30,195 patients were seen in the ED on Operation Telic and are available for analysis. Patients with ophthalmic complaints account for 5.3% of all presentations to the ED and rank as the 7th most common reason for attendance.

Conclusion

This paper identifies patterns of injury to enable future planning of equipment tables and identifies the need for prevention of injury wherever possible. Implications on days lost from full active duty for the injured can be extrapolated. More data needs to be collated on the use of eye protection and the relevance of contact lenses in deployed personnel with eye injuries.
Dietary Supplements and Military Operations: Caution is Advised
Authors: Boos Christopher , White SH , Bland SA , McAllister PD
Published: March 2013

We describe the case of a 32-year-old soldier who presented with acute organic psychosis during an operational tour to Iraq. This was precipitated by excessive consumption of caffeine coupled with additional use of oral nutritional stimulants. Her biochemical profile was compounded by the additional use of exogenous creatine. We present a brief overview of the issue of exercise supplementation and highlight some of the potential problems and clinical issues surrounding their use. This has important implications for both serving soldiers and the wider medical community.
An Unusual Case of Nerve Root Compression by Intradiscal Gas Pseudocyst of the Lumbar Spine
Authors: Yasuoka H , Nemoto O , Kawaguti M , Naitou S , Yamamoto K , Ukegawa Y
Published: March 2013

An Intradiscal gas collection, referred to as the vacuumdisc phenomenon (VDP) is a relatively common finding on radiographic studies of the lumbar spine, whereas gas-containing lumbar disc hernia is rarely observed. We report a case of a patient with left leg pain, provoked by a radiographically and surgically documented L4-5 gas containing disc hernia.
The Joint Theatre Clinical Case Conference (JTCCC): Clinical governance in action
Authors: Willdridge DJ , Hodgetts TJ , Mahoney PF , Jarvis L
Published: March 2013

Objectives

To quantify the type and nature of the lessons and issues arising from the Joint Theatre Clinical Case Conference.

Methods

An evaluation of all JTCCC minutes from inception on 30 Mar 07 to 05 Jun 08 (n=61) was performed in Jul 08. Each separate issue (n=207) was assigned a NATO ‘J’ category and further sub-divided into clinical and non-clinical issues. Detail of whether the issues were raised for information only, or required action to be taken was recorded, as was the outcome of this action.

Results

A wide range of clinical and non-clinical issues (J1-J8), were identified. 23% (47) of the 207 issues were raised for information only. 77% (160) issues required action to be taken. 109 were closed within 3 weeks. 23 took more than 3 weeks to close. Eight weeks after the study period 28 issues were still being actively resolved. 85% of JTCCC teleconferences had full participation from both theatres. Technical difficulties and/or the treatment of casualties prevented the participation of one or both theatres on 9 occasions.

Conclusions

JTCCC supports deployed clinicians and enables rapid resolution of issues affecting combat casualty care. It is limited by its focus on UK casualties only. Although intended as a Clinical Governance tool the evidence of this review is that JTCCC has wider effects in a number of clinical and non-clinical areas.
A Pain in the Neck
Authors: Newstead Dr Beth , Smith JE
Published: March 2013

Colonoscopy is a generally safe test whose use is rapidly increasing; complications are unusual and the accepted rate of perforation after diagnostic colonoscopy is between 1 in 800-1500 cases. Colonoscopic perforation may not be recognised at the time and the patient may present to a variety of medical practitioners after discharge from hospital. The presentation is usually with abdominal pain. We report an unusual presentation of colonoscopic perforation in which the patient attended the Emergency Department complaining of a painful neck.
Lessons Learned in Oral and Maxillofacial Surgery from British Military Deployments in Afghanistan
Authors: Gibbons A , N Mackenzie
Published: March 2013

This article describes the combined lessons learned from two deployments of a cadre of British Oral and Maxillofacial surgeons to Kandahar between July 2006 to April 2007, and September 2008 to April 2009.
A Travel Misadventure – Visceral Leishmaniasis in an Immunocompetent Patient
Authors: Delacour Hervé , Roche C , Roche B , Morand C
Published: March 2013

Visceral leishmaniasis is one of the world’s most neglected diseases. Over 90% of the 500,000 annual new cases occur in only five countries: India, Nepal, Bangladesh, Sudan and North-Eastern Brazil, but the disease remains endemic in Southern Europe. We report a case of visceral leishmaniasis in an immunocompetent serviceman after a seven-day stay in the Marseilles region of South-Eastern France. This case is intended to alert clinicians to the possibility of visceral leishmaniasis in patients who develop a febrile illness after returning from travel in Southern European countries.
The Doctor vs. the Command: Can Disagreement Arise?
Authors: Coetzee Rikus H , Simpson RG , Sharpley J
Published: March 2013

Doctors have long since assisted the Command on operations and in providing day to day bespoke medical care to the UK Armed Forces. Doctors and the Command work along different models that confer different obligations and priorities. For doctors the patient and their wellbeing is of primary importance and for the Command, the Unit as a whole with its military goals are of primary concern. Most of the time these two models work in harmony. However occasionally disagreement can arise. This article examines the models guiding their respective practice in order to understand the underpinnings of these disagreements, and offers some discussion of the issues, particularly as they pertain to the deployed environment. Finally, some recommendations are made to equip doctors and the Command to contain any disagreements.
The Management of Pancreatic Trauma
Authors: Khan MA , Cameron I
Published: March 2013

Pancreatic trauma is an uncommon occurrence and so a consensus about optimal management is not readily available. Isolated pancreatic injury occurs only occasionally, as in the majority of cases there is concurrent visceral or vascular injury. Morbidity and mortality are related to delay in diagnosis, concurrent organ injury or the presence and extent of pancreatic duct injury.
Managing Pain on the Battlefield: An Introduction to Continuous Peripheral Nerve Blocks
Authors: Hunter J G
Published: March 2013

Objective

To determine the strength of evidence supporting the battlefield use of Continual Peripheral Nerve Blocks (CPNBs).

Methods

Publication review identifying 380 potentially relevant papers.

Results

CPNBs have been well trialled and are used routinely in civilian hospitals. The procedure is not without acute and chronic complications related to agents used, catheters themselves and infection risks. These techniques are being used increasingly in military field hospitals to manage pain, however research concerning their use on the battlefield is limited and further trials are required to confidently conclude efficacy.

Conclusion

CPNBs are just one component within military medicine of a rapidly evolving polymodal system of pain management. Common combat wounds, namely traumatic amputations, are compatible with this technique, however current evidence concerning their battlefield use is limited. Extensive UK military trials are ongoing and the results of which are expected to clarify questions regarding complication rate and efficacy.
Compartment Syndrome of the Foot – Implications for Military Surgeons
Authors: Middleton Simon , Clasper J
Published: March 2013

Introduction

Compartment syndrome of the foot is a rare complication of injury to the foot. Treatment by decompression of the compartments is debatable. The debate surrounding decompression stems from the rarity of the condition, the lack of consensus regarding the anatomy of the foot compartments and whether to accept the inevitable contractures by not decompressing. The aim of this paper is two fold; firstly to sample current military orthopaedic experience and secondly establish if there exists a consensus of opinion in how and if to perform fasciotomy of the foot thereby providing guidance to other clinicians.

Method

A questionnaire was sent to 10 DMS orthopaedic consultants to identify their experience with foot compartment syndrome and performing foot fasciotomies.

Results

Five had performed a foot fasciotomy (average 2, range 1-6) over an average of 6.2 years as consultant and an average of 7.3 months deployed. Most commonly two dorsal and a medial incision were used to decompress the foot. One surgeon advocated not decompressing the foot and accepting the subsequent contractures,

Conclusion

DMS clinicians need to remain vigilant to compartment syndrome of the foot and especially in cases of crush or blast injury or of multiple fractures. If diagnosed or even if an impending compartment syndrome is suspected then, in line with the current weight of expert opinion, the foot should be decompressed and the deployed orthopaedic surgeon should be capable of performing it. Evidence concerning their battlefield use is limited. Extensive UK military trials are ongoing and the results of which are expected to clarify questions regarding complication rate and efficacy.
Noroviruses : A Challenge for Military Forces
Authors: Delacour Hervé , Dubrous P , Koeck JL
Published: March 2013

For military forces, the control of infectious acute gastroenteritis constitutes an old, constant and unsolved concern. Recent epidemiological studies suggest that the common bacterial causes are being overtaken by viruses. Norviruses are the most alarming group and norovirus outbreaks in military forces are regularly reported. Illness is generally mild and characterised by acute vomiting and diarrhoea, which lasts for a few days on average, but may be severe and potentially life-threatening in subjects who are already dehydrated due to daily activity. Moreover, outbreaks may diminish operational effectiveness. Prevention of norovirus infection currently relies on strict application of personal and collective hygiene rules including isolation of the cases, to the greatest possible extent. Although noroviruses are frequently mentioned as the cause of gastroenteritis outbreaks in troops deployed overseas, laboratory diagnosis is rarely done. So their real burden in military forces remains unclear and further epidemiological studies are required to determine the full impact of norovirus gastroenteritis on troops.
Acute Spinal Epidural Haematoma Causing Cord Compression After Chiropractic Neck Manipulation: An Under-recognised Serious Hazard?
Authors: Lidder Surjit , Lang KJ , Masterson S , Blagg S
Published: March 2013

Spinal manipulative therapy performed by chiropractors is increasingly common in the United Kingdom. Spinal epidural haematoma is a rare complication of such physical therapy but when identified represents a neurological emergency. We describe the case of a 64 year-old man who presented with a dense hemiplegia due to a spinal epidural haematoma following cervical spine manipulation performed for acute neck pain. The clinical features and surgical management of the case are discussed and we stress the importance of recognition of chiropractic manipulation as a potential cause of neurological sequelae and discuss the potential pitfalls of such therapy as it becomes more widespread.
Total Intravenous Anaesthesia for War Surgery
Authors: Lewis S , Jagdish S
Published: March 2013

Total Intravenous Anaesthesia (TIVA) and Target-Controlled Infusion (TCI) of anaesthesia are techniques that have benefited from recent advances in microprocessor technology and drug design. Though dependant on technology, they offer significant clinical benefits and logistic advantages. Manipulation of complex data derived from population pharmacokinetics has enabled greater understanding of drug handling models, thus enabling individual patient titration of anaesthesia. This has also informed manual techniques of intravenous anaesthesia. These approaches constitute a useful and logical alternative in the field, both in austere circumstances as well as the more established deployed setting. The pharmacodynamics and pharmacokinetics of potent intravenous anaesthesia agents in the complex combat trauma patient require continued examination.
Creating Airway Management Guidelines for Casualties with Penetrating Airway Injuries
Authors: Mercer Simon J , Lewis SE , Wilson SJ , Groom P , Mahoney PF
Published: March 2013

Anaesthetists in the Defence Medical Services (DMS) are currently dealing with casualties who have an increased prevalence of injuries due to blast, fragmentation and gunshot wounds. Despite guidelines already existing for unanticipated difficult tracheal intubation these have been designed for a civilian population and might not be relevant for the anticipated difficult airway experienced in the deployed field hospital. In order to establish an overview of current practice, three methods of investigation were undertaken; a literature review, a survey of DMS Anaesthetists and a search of the UK Joint Theatre Trauma Database. Results are discussed in terms of anatomical site, bleeding in the airway, facial distortion, patient positioning and an anaesthetic approach. There are certain key principles that should be considered in all cases and these are considered. Potential pitfalls are discussed and our initial proposed guidelines for use in the deployed field hospital are presented.
The Paediatric Transfusion Challenge on Deployed Operations
Authors: Bree Steve , Wood K , Nordmann GR , McNicholas J
Published: March 2013

This paper briefly touches on the problem of dealing with the severely injured child requiring massive transfusion and produces a guide on the management of this based on the current Surgeon General’s Operational Policy Letter. There are no known UK guidelines on massive transfusion in trauma in the paediatric population although many specialist centres have guidance for dealing with cases in theatre during elective surgery. It is hoped that these guidelines will be used by deployed military anaesthetists to aid in their management of these difficult cases, not normally seen in the UK.
Evolution of the Role 4 UK Military Pain Service
Authors: Devonport L , Edwards D , Edwards C , Aldington DJ , Mahoney PF , Wood Paul
Published: March 2013

The early development of the UK Role 4 pain service has already been described. This article will describe developments up to October 2010, and present the results of projects used in assessing the effect of this service.
Edgar Pask and his Physiological Research – An Unsung Hero of World War Two
Authors: Enever Gary
Published: March 2013

Edgar Pask died in 1966 at the age of 53. He was the Professor of Anaesthesia in Newcastle upon Tyne, and a quiet and unassuming man. But during the Second World War he had been involved in a number of dangerous and remarkable experiments; these included investigating the effects of acute hypoxia related to high altitude parachute descents, resuscitation techniques and the effectiveness of lifejackets.
Cardiovascular Physiology at High Altitude
Authors: Hooper T , Mellor Adrian
Published: March 2013

The role of the cardiovascular system is to deliver oxygenated blood to the tissues and remove metabolic effluent. It is clear that this complex system will have to adapt to maintain oxygen deliver in the profound hypoxia of high altitude. The literature on the adaptation of both the systemic and pulmonary circulations to high altitude is reviewed.
Acute Exposure to Altitude
Authors: Hodkinson Peter
Published: March 2013

Acute exposure to altitude principally encompasses aviation and space activities. These environments can be associated with very acute changes in pressure, oxygenation and temperature due to rates and magnitude of ascent that are not experienced in more chronic exposure such as mountaineering. The four key physiological challenges during acute exposure to altitude are: hypoxia (and hyperventilation), gas volume changes, decompression sickness and cold. The brief nature of aviation exposure to altitude provides little opportunity for acclimatisation, leading to markedly different effects when an individual is exposed to the same altitude acutely compared with an acclimatised individual climbing an 8000m (26 347ft) peak. Challenges such as hypobaric decompression sickness are not considered a hazard for chronic altitude exposure but are routine considerations for those flying to high altitude. Protective systems are essential for aircrew and passengers to survive and function during acute exposure to altitude.
Causes of Injuries in the Mountains: A Review of Worldwide Reports into Accidents in Mountaineering
Authors: Knott J W
Published: March 2013

This review presents a selection of sources from the UK and around the world that have reported on both incidents and accidents in the mountains. Common themes are extracted to illustrate the circumstances under which accidents, injuries and fatalities occur and the underlying factors that have contributed to incidents in the first place. There is an attempt to dispel some ‘myths’ surrounding accidents in mountain based activities. The purpose of highlighting these issues is to allow those undertaking them to understand where the greatest risks lie. This enables the individual, team leaders, rescue services and those involved in the overall management of wilderness areas to plan accordingly, with the aim of reducing injuries and deaths.
Systemic Blood Pressure, Arterial Stiffness and Pulse Waveform Analysis at Altitude
Authors: Rhodes HL , Chesterman K , Chan CW , Collins P , Kewley E , Pattinson KTS , Myers S , Imray CHE , Wright A D
Published: March 2013

Objectives

Systemic arterial pressure rises on acute exposure to high altitude and changes in blood pressure (BP) and endothelial function may be important in the pathogenesis of clinical syndromes occurring at high altitude.

Methods

Arterial BP, stiffness (SI) and tone (RI) were studied over 11 days in 17 subjects (three having mild hypertension) ascending to 3,450m and 4,770m using a non-invasive, finger photoplethysmography technique.

Results

At 3,450m BP rose from mean 131/75 mmHg (SD 23/12) to 145/86 (23/12) and was maintained at this level (p< 0.001). SI did not change significantly from 8.5 m/sec (2.5) to 9.7 (3.2). RI fell during the first day at 3,450m from 74.4% (7.9) to 70.5% (13.8) (NS p>0.05) and to 69.9% (12.0) (p< 0.02) at 4,770m but then reverted to baseline. Changes in SI and RI did not relate to changes in blood pressure. Changes in both arterial stiffness and tone were similar in those who developed AMS compared with those who did not. Baseline SI tended to be higher in the three subjects with hypertension 11.1m/sec(SD 2.7)) compared with the normotensives 8.3 m/sec (SD 2.7) (NS) and baseline RI lower 74.7% (7.0) compared with the normotensives 76.5% (8.5) (NS). Changes in SI and RI at altitude in the hypertensive subjects were similar to the non-hypertensive subjects.

Conclusions

We conclude that acute exposure temporarily affected endothelial function as measured by a change in vascular tone but this did not predict the development of AMS. The rise in arterial BP was not related to changes in arterial stiffness or tone.
A Day in the Life of a Doctor Working at The Himalayan Rescue Association
Authors: Stokes Suzy , Mackenzie S
Published: March 2013

The Himalayan Rescue Association’s (HRA) clinic in Pheriche, Nepal (4243m) is one of a number of high altitude medical posts where demands for services are increasing. Every year international doctors see over 1000 patients, assisting local people with basic health needs and providing emergency care for trekkers with both altitude-related and general illnesses and injuries. This article describes the work of the voluntary clinic and some of the challenges it faces.
Historical Origins and Current Concepts of Wound Debridement
Authors: Guthrie HC , Clasper JC
Published: March 2013

In the late 18thCentury wound debridement consisted of incision of skin and deep fascia to release the swelling associated with ballistic injury, however extremity war wounds were more usually managed non-operatively or by amputation. During the First World War debridement was redefined to include excision of all non-viable and foreign material. In the modern era it has been proposed that wounds contain a zone of injured tissue which is not obviously non-viable at the initial debridement. Debridement which preserves this tissue has been described as marginal debridement. Wounds sustained in close proximity to explosions have an extensive zone of injury. Preservation of traumatised tissue may be beneficial in terms of limb salvage and limb reconstruction. Equally the complexity and contamination of these wounds, as well as the physiological frailty of the casualty, may make complete debridement in one sitting an unachievable goal. Where traumatised tissue has been left during debridement it must be reassessed at around 48 hours in order to reduce the risk of infection. Evacuation timelines and logistic infrastructure currently support serial marginal debridement but in future conflicts this may not be the case.
Liver Trauma - Operative Management
Authors: Morrison JJ , Bramley KE , Rizzo AG
Published: March 2013

Civilian liver trauma is generally sustained by blunt injury, with management strategies increasingly focusing on selective non-operative strategies and endovascular intervention. Military liver trauma is more often ballistic in nature and almost always requiring operative intervention. This article reviews established and evolving surgical techniques in the operative management of liver trauma.
Improvements in Compliance with Medical Force Protection Measures by Simplification of the Anti-Malarial Chemoprophylaxis Regime
Authors: Sellers Emma , Ross DA , Green AD
Published: March 2013

Objectives

Medical Force Protection (MFP) is important in keeping service personnel “fit to fight.” It is particularly important for overseas deployment, where personnel are exposed to a range of infectious diseases. We report a full audit cycle assessing compliance with medical force protection measures, on an exercise in Belize.

Methods

An anonymous questionnaire was administered to personnel four weeks after returning from an Infantry Overseas Training Exercise (OTX) in Belize in two successive years (OTX 1& 2).

Results

Compliance with physical MFP measures (mosquito nets, insecticide soak of kit and personal insect repellent usage) was excellent on both exercises. Antimalarial chemoprophylaxis compliance with a regime of weekly chloroquine and daily proguanil was poor (30%) during OTX 1. Revision of the regime to weekly chloroquine alone following review of anti-malarial policies increased compliance on OTX 2 to 67%.

Conclusion

Simplification of dosage regimes, consistency of information provided between different medical briefs and emphasis of the threat from malaria in Belize significantly improved compliance with antimalarial chemoprophylaxis.
Bilateral Hip Fractures Associated with Transient Osteoporosis of Pregnancy
Authors: Lidder Surjit , Lang KJ , Lee H-J , Masterson S , Kankate RK
Published: March 2013

A case of transient osteoporosis of pregnancy complicated by bilateral neck of femur fractures is reported. We discuss the condition and review the literature, provide information to aid in the diagnostic dilemma clinicians may face when considering imaging techniques and the potential for foetal harm during radiation exposure. We discuss management strategies in such patients.
Renal Replacement in the Deployed Setting
Authors: Nesbitt Ian , Almond MK , Freshwater DA
Published: March 2013

We present a case of a UK soldier suffering multiple injuries in Afghanistan including a lacerated liver, complicated by acute anuric renal failure. His condition was stabilised prior to transfer to the UK using continuous venovenous haemofiltration. This is the first deployed use of renal replacement therapy by UK forces for several decades, and raises questions regarding the provision of this high level capability in the deployed setting.
A Three-Year Review of Emergency Department Admissions - Op HERRICK 4 to 9
Authors: Stalker Andrew , Ollerton J , Everington S , Russell R , Walker C , White S
Published: March 2013

Objectives

This paper describes the key themes in presentations to the Emergency Department (ED) of the UK Field Hospital throughout the three-year period of April 2006 to April 2009 (Op HERRICK 4-9).

Methods

Electronic ED attendance records held in the Operational Emergency Department Attendance Register (OpEDAR) were analysed with validation by Defence Analytical Services Agency and commentary by ADMEM clinical staff.

Results

This paper discusses absolute numbers of emergency department attendances of which there were 11,158 recorded over the study period. It does not compare them to personnel at risk or operational tempo. Of these attendances, 59.7% (n=6,666) were UK military. Explosive injuries (15.2%, n=1,699), particularly Improvised Explosive Devices, increased throughout the period as did gunshot wounds (7.3%, n=809). Battle injuries represented 23.3% (n=2,602) attendances and had a fatality rate of 10.9%. 38.8% (n=4,327) of attendances were non-battle injuries and had a fatality rate of 0.4%. There were no fatalities in the 34.1% (n=3,800) attendances for disease. 315 fatalities were recorded (this figure relates to all attendances – not just UK personnel) with 90.2% (n=284) due to battle injuries. 59.4% (n=187) were due to explosives and 28.9% (n=91) due to gunshot wounds.

Conclusions

Over the period, the hospital’s workload was characterised by an increase in explosive and gunshot injuries. In this role, the hospital met its obligation of responding to traumatic battle injury in support of fighting power and morale. Equally, the hospital faced a high proportion of attendances for non-battle injury and illness, and by patients from the local population. Extrapolation of data enables accurate medical planning and pre-deployment training and facilitates preparation for current operations.
The Immediate Treatment of Frostbite in the American and German Armies in Europe During World War 2: An Historical Perspective
Authors: Defalque RJ , Wright AJ
Published: March 2013

This historical account, based on a survey of 250 medical articles written during and immediately after World War II, reviews the immediate treatment of frostbite in the American and German ground troops in Europe from 1941 to 1945. The American management was simpler and more conservative than the elaborate treatments reported in the German publications. Because the German patients’ injuries were more severe than those of the American soldiers and because neither Army carried out strict clinical trials nor prolonged follow-ups, it is impossible to judge what treatment was superior.
Cystic Fibrosis Compatible With a Full Term Army Engagement
Authors: Jackson S M-J S , Cooper NK
Published: March 2013

A case of a specialist Senior Non-Commissioned Officer with Cystic Fibrosis (CF) is described. Partial expression of the CF trait is well known and sporadic cases are detected from time to time at recruitment, during recruit training and service. Respiratory symptoms may be mis-diagnosed as self-limiting asthma until a sweat chloride or other specific test for CF is performed.
Difficult Decisions in the Surgical Care of Military Casualties with Major Torso Trauma
Authors: Bowley DM , Jansen JO , Nott D , Sapsford W , Streets CG , Tai Nigel
Published: March 2013

Testing and difficult decision-making is a sine qua non of surgical practice on military operations. Better pre-hospital care protocols, reduced evacuation timelines and increased scrutiny of outcome have rightfully emphasised the requirement of surgeons to “get it right, first time and every time” when treating patients. This article addresses five contentious areas concerning severe torso trauma, with relevant literature summarised by a subject matter expert, in order to produce practical guidance that will assist the newly deployed surgeon in delivering optimal clinical outcomes.
Nutritional Management of Critically Ill Trauma Patients in the Deployed Military Setting
Authors: Jansen JO , Turner S , Johnston AMcD
Published: March 2013

The role of nutritional support in critical illness is well established. This article reviews the nutritional management of military trauma patients in the deployed setting, which poses special challenges for the surgeon and intensivist. There is little direct evidence relating to the nutritional management of trauma patients in general, and military trauma patients in particular, but much of the evidence accrued in the civilian and non-trauma critical care setting can be extrapolated to military practice. There is strong consensus that feeding should be commenced as soon possible after injury. Enteral nutrition should be used in preference to parenteral nutrition whenever possible. If available, supplemental parenteral feeding can be considered if enteral delivery is insufficient. Gastrointestinal anastomoses and repairs, including those in the upper gastrointestinal tract, are not a contraindication to early enteral feeding. Intragastric delivery is more physiological and usually more convenient than post- pyloric feeding, and thus the preferred route for the initiation of nutritional support. Feeding gastrostomies or jejunostomies should not be used for short-term nutritional support. Enteral feeding of patients with an open abdomen does not delay closure and may reduce the incidence of pneumonia, and enteral nutrition should be continued for scheduled relook surgery not involving hollow viscera or airway. Glutamine supplementation may improve outcome in trauma patients, but fish-oil containing feeds, while showing some promise, should be reserved for subgroups of patients with ARDS.
The Deployed Medical Director: Managing the Challenges of a Complex Trauma System
Authors: Mahoney PF , Hodgetts TJ , Hicks I
Published: March 2013

Contemporary combat casualty care has never been more sophisticated or effective, which is matched by an unprecedented level of clinical complexity. The management of this complexity has demanded the evolution of a more direct clinical leadership model in the field hospital: the Deployed Medical Director (DMD). The DMD has a central co-ordinating role in reducing the friction generated by individuals’ unfamiliarity in a rapidly developing clinical environment that has diverged from the NHS; in cementing interoperability within a multinational medical treatment facility working at high intensity; and in maintaining and developing the highest clinical standards within the deployed trauma system. This article describes the evolution of the DMD role and illustrates the challenges through a series of vignettes. Particular emphasis is given to the organisational risk that the role carries through necessary ethical choices, the requirement to integrate multi-national cultural differences and the challenge of dealing with interpersonal frictions amongst senior staff.
Body Contouring Surgery for Military Personnel Following Massive Weight Loss
Authors: Chong SJ , Kok Yee Onn , Foo CL
Published: March 2013

The burgeoning global obesity epidemic extends to the military service, where 6 - 53% of military personnel are overweight. Obese military personnel who adhere to a strict training and diet regime may potentially achieve and maintain significant weight loss. They may however face physical problems such as excess skin folds causing discomfort, difficulty in uniform fitting, personal hygiene, interference with full physical activities and psychological issues such as body image dissatisfaction, low self esteem and difficulty in social acceptance. We present a case report of a highly motivated military conscript who achieved and maintained significant weight loss but had physical defects following Massive Weight Loss. Body contouring surgery was successfully utilised to correct his physical defects and allowed him to return to full physical duties.
The Context for Planning Military Health Services Support
Authors: Bricknell Martin CM , Beardmore CE
Published: March 2013

This article is designed to provide a short summary for medical personnel with limited military experience to understand how the medical staff function works within a military headquarters. It places planning military health services support in the context of wider planning for military operations. It starts by examining the Contemporary Operating Environment and the role of military forces within it, then considers the generic military planning process and how the medical staff in a headquarters plan the medical support to military operations. The final element of the article is a discussion of the composition of the personnel required within a medical branch in a military headquarters.
Medical Planning and the Estimate
Authors: Bricknell Martin CM , Williamson RHB
Published: March 2013

This paper examines the principles of medical planning with consideration of the formal planning tool ‘the Estimate’. It describes a generic structure for the medical aspects of the Estimate. The paper also shows how military medical planning must be tightly linked to wider general staff planning processes and how staff analyses lead to a formal medical plan.
Casualty Estimation and Medical Resource Planning
Authors: Bricknell Martin CM , Jones FR , Hatzfeld JJ
Published: March 2013

This paper considers casualty estimation and the link between historical evidence and prospective forecasting of demand for medical resources. It considers the purpose of casualty estimation at each level in the chain of command, reviews the historical uses of casualty estimation and considers the methodological approaches to casualty estimation. The link between historical evidence and future planning is demonstrated, and the use of casualty estimation within the medical planning process is examined.
Outcomes from Penetrating Ballistic Cervical Injury
Authors: Breeze J , Masterson L , Banfield G
Published: March 2013

Aims

Ballistic cervical injury has become a significant source of both morbidity and mortality for the deployed UK soldier.The aim of this paper was to document a case series of ballistic cervical wounds to describe the pattern of these injuries and relate them to outcome.

Methods

The records of all UK service personnel sustaining wounds to the neck in Iraq or Afghanistan between 01 August 2004 and 01 January 2008 were analysed following identification by the Joint Theatre Trauma Registry. Blunt or thermal injuries were excluded.

Results

The records of 75/76 service personnel sustaining penetrating cervical injury during this period were available for analysis. 56/75 (75%) were due to explosive fragmentation and the remainder due to gunshot wounds (GSW). 33/75 (44%) of soldiers sustained vascular injury, 32/75 (43%) injury to the spine or spinal cord, 29/75 (39%) injury to the larynx or trachea and 11/75 (15%) injury to the pharynx or oesophagus. 14/75 (19%) patients in this series underwent surgery in a hospital facility for treatment of potentially life threatening cervical injuries, with a survival rate after surgery of 12/14 (86%). The overall mortality from this series of battlefield penetrating neck injury was 63%.

Conclusions

Penetrating cervical ballistic injury is a significant source of injury to deployed UK service personnel, predominantly due to neurovascular damage. Neck collars if worn would likely prevent many of the injuries in this case series but such protection is uncomfortable and may interfere with common military tasks. Newer methods of protecting the neck should be investigated that will be acceptable to the deployed UK soldier.
Management of a Wild Animal Bite in a Rabies Enzootic Area
Authors: Ross John , Raitt S
Published: March 2013

The British Armed Forces of the 21stCentury are trained and operate worldwide, often in places where rabies control is poor and prevalence may be high. Currently rabies is not a routine vaccination for all service personnel. Awareness of the risk of rabies, action to take post potential exposure, prompt access to clear management advice and reliable supplies of Rabies Immunoglobulin and Rabies Vaccination are critical. We describe the management of a recent case of animal bite in Kenya and discuss current recommendations.
An Account of Multiple Casualties in an Austere Environment
Authors: Reynolds ND , Dalal S
Published: March 2013

A satellite compound of an International Security Assistance Force Patrol Base came under assault during OP HERRICK 12 resulting in eight casualties. Multiple fragmentation type injuries were sustained over a short period of time which tested the locations medical capacity. This account describes the events that occurred in extracting and treating those injured.
To Refer or Not to Refer: A Qualitative Study of Reasons for Referral From Role 1
Authors: Driver Jamie , Nelson TG , Simpson R , Wall C
Published: March 2013

Objectives:

There are currently over 9000 British soldiers serving in Afghanistan. The Defence Medical Services provide primary health care to soldiers at forward locations using Regimental Medical Officers (RMOs) and General Duties Medical Officers (GDMOs). If required, GDMOs can refer patients to senior colleagues. Currently, little is known about the reasons for referrals by GDMOs. This study aims to identify the main factors affecting why GDMOs refer from forward locations.

Methods:

Nine GDMOs, who deployed on Operation HERRICK 13, were invited to join the study. They maintained a log of their referrals for two 14 day periods, one in each half of their tour. In addition, a semi-structured interview was performed with each GDMO in order to elicit the common themes surrounding referrals.

Results:

The mean referral rate was 0.9 referrals/GDMO/week. The main reasons for referral were dental problems, musculoskeletal injuries, abdominal pain of unknown cause, and ano-genital problems. Factors that influenced referrals included availability of forwardly projected services (dentist and physiotherapist), manpower availability at the locations, the availability of flights (affected by weather, enemy action, and schedule of routine flights), and the timing of the tour in relation to leave.

Conclusions:

Referrals from GDMOs were due to doctor inexperience in the treatment of a particular condition, lack of access to investigations and the potential for deterioration in a location without adequate support. The referral decision process was affected by the patient’s importance with regards to the mission, the weather and access to safe transportation. The introduction of clinical guidelines for common conditions in conjunction with minor alterations to GDMO training could help reduce referrals from Role 1, preserving manpower, reducing costs, and minimising risk to evacuation aircraft.
Beware the BATUS Cactus – Cactus Dermatitis in Exercising Soldiers on the Albertan Prairie
Authors: Whitaker John , Bailey KG
Published: March 2013

Species of the Opuntia or prickly pear genus of cacti are endemic to the British Army Training Unit Suffield (BATUS) training area in Alberta, Canada. They are known to provoke a dermatitis reaction in harvesters of the cacti fruit. It’s spines are frequently an uncomfortable nuisance to unwary soldiers exercising in BATUS. We report two cases of particularly debilitating adverse skin reactions to the cacti spines that occurred during the 2010 Exercise Prairie Thunder season.
High Altitude Cerebral Oedema During Adventure Training on Mount Kenya
Authors: Raitt S
Published: March 2013

The trekking ascent to Point Lenana (4,985m) on Mount Kenya is a popular objective for soldiers on adventurous training in Kenya. The standard route previously taken has been the Naro Moru route which involves an ascent rate far in excess of that recommended to avoid altitude illness. This article describes the case of a British soldier who developed high altitude cerebral oedema during an ascent of Point Lenana via the Naro Moro route. Recommendations to reduce the risk of altitude illness on Mount Kenya include alternative and more gradual routes of ascent. Early symptom recognition and descent are vital to prevent clinical deterioration.