bluuebunny/crossref_metadata_2025 huggingface dataset:
Are Soldiers at Increased Risk of Third Molar Symptoms when on Operational Tour in Iraq? A Prospective Cohort Study
Authors: Breeze J , Gibbons AJ
Published: March 2013

Objective

Pain associated with third molar (wisdom) teeth is a common cause of morbidity for soldiers in the United Kingdom and on operational deployments. This study compared the incidence of third molar symptoms between soldiers serving in Iraq and soldiers stationed in barracks in Northern Ireland and assessed if pre-deployment screening could be improved.

Method

Data was collected in a prospective cohort study over five consecutive months. Dental officers recorded each time an Army soldier presented with third molar related symptoms.

Results

1% of soldiers in Iraq had third molar related symptoms in this time compared to 1.4% of those stationed in Northern Ireland. The range of pathologies and teeth affected were similar between locations. In both locations approximately 40% of teeth that caused problems had been symptomatic before and 13 -16% had untreated decay.

Conclusions

This study suggests that soldiers experience a lower incidence of symptoms related to third molars when in Iraq compared to Northern Ireland (P<0.033) possibly due to pre-deployment treatment. If ideal pre-deployment screening of third molars was carried out and National Institute of Clinical Excellence guidelines applied 38% of the Operation Telic group of patient’s problems could have been prevented.
Military Sports and Rehabilitation Medicine
Authors: Dharm-Datta Shreshth , Nicol E
Published: March 2013

This article summarises the presentations at the Sports Medicine and Rehabilitation Study Day held by the Haywood Club at The Medical Society of London on 21 September 2006. The event was attended by over 100 serving and retired DMS personnel and included talks on a diverse range of subjects from the newly established speciality of Sports and Exercise medicine, the role of physiotherapy, exercise therapy and podiatry, core stability, tendon disorders, anterior knee pain, and the management of chronic pain.
Analysis of the Initial 100 Scans from the First CT Scanner Deployed by the British Armed Forces in A Land Environment.
Authors: O’Reilly David , Kilbey J
Published: March 2013

Aims

To examine usage of the first CT scanner installed in a UK field hospital, BMH Shaibah, over a 13 month period.

Methods

All request forms and reports for the first 100 studies were analysed retrospectively.

Results

An average of 7.7 scans per month was performed. Trauma was the most common indication followed by urinary symptoms and headache. Significant pathology was diagnosed in many cases.

Conclusion

A deployed CT scanner can make a significant contribution to the capability of a field hospital, shaping both the management and disposal of patients. A more easily deployable scanner will be needed in future.
Shaped Charges and Explosively Formed Penetrators: Background for Clinicians
Authors: Morrison JJ , Mahoney PF , Hodgetts T
Published: March 2013

Shaped Charges (SC) have been used in High Explosive Anti-Tank (HEAT) munitions and the mining industry since World War II. An explosive is used to propel a liner material of low mass at speeds in excess of 5 times the speed of sound. The subsequent projectile is capable of penetrating the steel of armoured vehicles and inflicting significant injury to any enclosed personnel. Explosively Formed Penetrators (EFP) are a variant of a SC, using higher mass at lower speed to deliver their kinetic energy. The Iraq conflict has seen the use of Improvised Explosive Devices utilising EFP (IED-EFP) by insurgent groups attacking military vehicles. The major wounding mechanisms are from fragmentation and burns. This article is a brief overview of the history and science behind SC and EFP.
Operational Morbidity Analysis of Soft Tissue Injuries During Operation Telic
Authors: Ollerton JE , T Hodgetts , R Russell
Published: March 2013

Soft tissue injury accounted for one in five of all presentations to the Emergency Department (ED) during Operation TELIC (UK forces in Iraq) from March 2003 to November 2006. This ranks soft tissue complaints as the most frequent cause of attendance to a deployed field hospital ED. This paper analyses the injury patterns, together with implications for future clinical practice and operational planning to prevent injury, optimise patient care and maximize force regeneration.
UK Defence Medical Services Guidance for the Use of Recombinant Factor VIIA (RFVIIA) in the Deployed Military Setting
Authors: Hodgetts TJ , Kirkman E , Mahoney PF , Russell R , Thomas R , Midwinter M
Published: March 2013

Use of recombinant Factor VIIa (rFVIIa) for trauma is currently an ‘off label’ use.

There are reports of rFVIIa contributing to the successful outcome of military trauma patients. This paper sets out the current position of the UK Defence Medical Services with regard to using rFVIIa in military trauma.
Intra-Osseous Access (EZ-IO®) for Resuscitation: UK Military Combat Experience
Authors: BR Cooper , Mahoney Colonel P , TJ Hodgetts , A Mellor
Published: March 2013

Military trauma produces predominantly blast and fragmentation injury, commonly resulting in haemorrhagic shock. Injury patterns to limbs are such that the conventional sites for venous cannulation may be unsuitable. The EZ-IO® (Vidacare®, San Antonio) system is one of a number of novel products designed for intraosseous (IO) access in adults or children. In three months of combat casualty care in Helmand Province, Afghanistan, the UK Defence Medical Services used EZ-IO® for emergency vascular access on 26 patients (16 adults; 10 children). 23/26 patients had IO access obtained in the emergency department; 3/26 had pre-hospital IO access within a tactically flying helicopter. A total of 32 needles were inserted, with 97% effective function. IO needles were used to administer fluid (crystalloid, packed red cells and fresh frozen plasma) and drugs (analgesics, cardiac arrest drugs, antibiotics, drugs for both rapid sequence induction and maintenance of anaesthesia). No complication of infection was noted, but pain was observed in responsive patients with the pain of infusion exceeding that of the underlying injuries in 3 cases.
Getting The Best of Both Worlds – Clinical Excellence at a Peripheral Unit
Authors: Day T K , Veen H
Published: March 2013

Audit of hospital practice in remote areas and military practice indicates that it is possible to provide a high degree of patient safety with the advantages of care close to home in a small hospital with less than 100 beds. However such an approach requires strict attention to training and retraining, good clinical networking, attention to quality control and a well defined system for identifying those patients who need to be transferred to a specialist centre.
An Unusual Case of Sinusitis
Authors: Lamb LEM , Richards P , Edgar JDM
Published: March 2013

Background

Common Variable Immunodeficiency (CVID) is the commonest form of severe antibody deficiency. It is characterized by reduced levels of IgG (<400mg/dL) and low IgA and/or IgMlevels, recurrent bacterial infections, impaired antibody responses despite the presence of B Cells and normal or near normal T immunity in 60% of patients. There is a high mortality from infections without treatment. The main stay treatment is to replace the immunoglobulins.

Case Presentation

We describe a British soldier with a 10 year history of recurrent chest infections, sinusitis and otitis media. He repeatedly presented 2 to 3 times a year complaining of either a green nasal discharge or a cough productive of yellow/green sputum. He presented three years ago with severe sinusitis which resulted in investigations highlighting hypogammaglobulinaemia. Subsequently he was started on immunoglobulin therapy with Flebogamma 40g three weekly.

Recommendations

Despite being a relatively rare condition, CVID when diagnosed, can be easily treated and improve patients' prognosis. Medical Officers should be aware of the condition as a differential diagnosis for individuals presenting with recurrent infections.
Trauma Risk Management (TRiM) in the UK Armed Forces
Authors: Greenberg N , Langston V , Jones N
Published: March 2013

Trauma Risk Management (TRiM) is a novel system of post incident management which intend to allow commanders to provide appropriate support to their subordinates in the aftermath of traumatic events. Given the current very considerable operational tempo being experienced by the majority of the UK Armed Forces, it is perhaps not surprising that TRiM has been in use in both Iraq and Afghanistan. Although TRiM originated from within the Royal Marines, it is now widely used in both the Royal Navy and Army; there are also plans to introduce it into specific components of the Royal Air Force such as for the RAF Regiment. This paper aims to explore the basis behind the TRiM system and to explore the evidence for its growing popularity within hierarchical organisations such as the military.
“What Else is There to Do?” – A Qualitative Study of the Barriers to Soldiers Stopping Smoking
Authors: Owers Russell C , Ballard KD
Published: March 2013

Objectives

To investigate the impact of Army life on soldiers’ motivation for stopping smoking.

Method

A two stage study using a questionnaire to identify smokers in a British Army infantry battalion of 560 soldiers based in the United Kingdom with either a low or high intention to quit smoking, followed by semi-structured interviews of a purposive sample of 18 respondents.

Results

31.3%of soldiers were current smokers. In addition to recognised barriers to stopping smoking, the interview data revealed structural and cultural barriers, some of which are unique to the Army. Structural barriers included an increased opportunity to smoke in terms of time, place, and cost. Cultural barriers included peer pressure, the smoking norm, and a lack of discouragement from the ‘regimental family’. These barriers to stopping smoking often arise from established British Army values and standards. For example, the need for punctuality requires early arrival at destinations, which in turn, provides an increased time opportunity to smoke. Other attitudes that the Army wishes to encourage, such as building teamwork and interdependence, can also be enhanced through smoking.

Conclusion

Whilst the numerous, previously identified barriers to stopping smoking exist within and outside the armed forces, specific additional barriers arise from the structure and culture of the Army. Changes in the structure of daily life within the Army may reduce the barriers to stop smoking. Army clinicians also play an important part in soldiers’ stopping smoking and an increased understanding of the specific barriers to stopping smoking may help them to support soldiers more effectively.
Viral Gastroenteritis Outbreaks in Deployed British Troops During 2002-7
Authors: Bailey Mark S , Gallimore CI , Lines LD , Green AD , Lopman BA , Gray JJ , Brown DWG
Published: March 2013

Objectives

The aim of this study was to see what lessons could be learnt from the suspected viral gastroenteritis outbreaks that have occurred in deployed British troops during 2002-7.

Method

Epidemiological and laboratory data from identifiable outbreaks were reviewed, including epidemic curves and the results of PCR testing for enteropathic viruses.

Results

The epidemic curves of outbreaks varied predictably in accordance with the size of the population at risk and whether this population was constant or expanding. Of 11 outbreaks identified, 10 (91%) had a proven viral cause and 10 (91%) occurred in Iraq. Of 84 enteropathic viruses identified, 61 (73%) were noroviruses and these included both unknown strains and those that were common in the UK and Europe. Of the 10 viral outbreaks, 3 (30%) occurred in medical units, 5 (50%) were associated with large-scale relief in place (RiP) deployments and 5 (50%) involved >3 different viruses, which is strongly suggestive of food or water contamination.

Conclusion

These findings can help to predict future viral gastroenteritis outbreaks and target improved prevention strategies appropriately. However, more systematic studies are now required.
The Management of Acute Diarrhoea in a Healthy Adult Population Deploying on Military Operations
Authors: Bourne Simon , Petrie C
Published: March 2013

Acute diarrhoea is consistently the number one presentation to secondary care facilities on UK military operational deployments. It can result in potentially life threatening consequences as seen on Operation Herrick in 2002, where a Norwalk-like virus caused 3 cases of meningo-encephalitis. Due to the circumstances of communal accommodation, ablutions and dining facilities, even mild cases are admitted at role 2, and personnel are not discharged until fully recovered in order to prevent potential outbreaks. This literature review examines the management of acute diarrhoea in healthy adults relating to UK military operations, and presents a management algorithm suitable for any theatre. The importance of the initial assessment is highlighted and allows the severity of the condition to be assessed using three key parameters. We recommend the selective use of stool culturing for severe cases and outbreaks. The use of oral re-hydration solutions vs. intravenous fluids, and the indication for the safe use of anti motility agents and antibiotics for diarrhoea are discussed. Where pathogens are yielded local sensitivities should guide the choice of treatment. Salmonella spp and Shiga toxinproducing E.coli (STEC) should receive supportive care only.
‘Wristwatch Fracture’ of the Distal Radius: A New Diagnosis?
Authors: Yewlett AD , Khan R , Clasper J
Published: March 2013

Segmental forearm fractures are relatively uncommon in children, and their optimal management is unclear. We present an unusual segmental fracture of the distal radius in a 14 year old that appears to be related to a large metal wristwatch worn by the patient. It was successfully managed by closed reduction and immobilisation in a plaster cast.
Audit of the Effectiveness of Command and Control Arrangements for Medical Evacuation of Seriously Ill or Injured Casualties in Southern Afghanistan 2007
Authors: Cordell Brigadier Robin , Cooney MS , Beijer D
Published: March 2013

Aims

The effectiveness of the command and control of medical evacuation by helicopter (MEDEVAC) of casualties sustained in southern Afghanistan each month from 1 May to 31 July 2007 was audited. In this period 762 casualties of all categories were evacuated to International Security Assistance Force (ISAF) field hospital facilities under the direction of Operations and medical staff of NATO Regional Command (South) (RC-S).

The criterion for the audit was the time taken from notification in the RC-S Combined Joint Operations Centre (CJOC) until the helicopter landed (“Wheels Down”) at the destination field hospital’s helicopter landing site. The standard to be met was 90 minutes for all “9-liner” Category A (URGENT) and Category B (URGENT – surgical) cases (in hospital within 2 hours of wounding) allowing for time from injury to first notification in the CJOC, and time from landing to transfer to the Emergency Department (30 minutes together) at the designated destination hospital. Those that did not meet this target were assessed in order to review their outcome and to identify means for improving performance.

Results

Analysis of evacuation times for all missions each month from May to July revealed that three quarters of A and B category missions met the 90 minute target. No adverse outcome resulted from those which did not meet this target, reasons for which included distance (more than 30 minutes flying time each way), delay in securing a hostile landing site, delay in obtaining sufficient information, incorrect categorization of the casualty’s priority, and on one occasion, an overmatch of assets available at that time. No casualties died who were recoverable.

Comparison with data from the two previous RC-S rotations (prior to 1 May 07) showed an improvement in mean response time, but little change in median response on the rotation of RC-S staff on 1 May 07. The major change that had occurred on this rotation was to move the medical operations staff into the CJOC. The convergence of median and mean at this time indicates a reduction in “outliers”, providing evidence that collocation of medical and operations staff improves incident response and should be the “default setting” in deployed tactical formation headquarters.

Conclusion

Regular audit of MEDEVAC response should be routine for Medical Operations staff, in order to ensure the optimal casualty care pathway from point of wounding to field hospital.
The Use of Improvised Bullet Markers with 3D CT Reconstruction in the Evaluation of Penetrating Trauma
Authors: Ramasamy Arul , Hinsley DE , Brooks AJ
Published: March 2013

Radio-opaque markers placed over entry and exit wounds, have been used to help evaluate penetrating injuries and provide a permanent record of wound location on plain radiographs. To date there are no published reports of the application of improvised bullet markers in the evaluation of penetrating injuries using computed tomography (CT). We report a series of 4 cases where bullet markers were used in combination with three-dimensional (3D) computerised tomography (CT) to ascertain the path of the bullets and to assess damage to vital structures. We believe that the use of bullet markers in penetrating trauma casualties undergoing CT is valuable in the surgical decision making process and allows planning of surgical approaches.
Abdominal Injury Due to a Hand Held Flare: An Ongoing Insult
Authors: Neequaye S , Gill J , Hance J , Sivagnanam P , Rutter P
Published: March 2013

Although traumatic abdominal missile injuries have been previously widely reported, there are no reports on penetrating hand held flare injuries. We report a case of a penetrating abdominal flare injury and the subsequent complications that occurred as a result of this unique injury.
The Use of Opioids During Rehabilitation after Combat-Related Trauma
Authors: Jagdish S , Aldington D
Published: March 2013

Opioids constitute an important component of analgesic regimens and in the UK military, they are used throughout the journey of the wounded soldier. Concerns have been expressed about their usefulness and potential adverse effects when they are continued beyond the acute phase into rehabilitation. The current literature regarding opiod usage during rehabilitation is reviewed in order to provide evidence based recommendations for practice with particular relevance to recentmilitary experience.
The Early Detection and Management of Neuropathic Pain Following Combat Injury
Authors: Mercer SJ , Chavan S , Tong JL , Connor DJ , de Mello WF
Published: March 2013

The mechanism of injury on the modern battlefield results in a pattern of wounding which is associated with both nociceptive and neuropathic pain. Nociceptive pain is managed using the WHO Analgesic Ladder but neuropathic pain requires the use of co-analgesic drugs, e.g. antidepressants and anticonvulsants. This study was designed to determine the incidence of neuropathic pain within military casualties with limb injuries. From May to November 2007, 50 casualties were interviewed and assessed using the Leeds Assessment of Neuropathic Symptoms and Signs Scale (LANSS) over consecutive weeks. During the first week post injury, 30%of casualties had a LANSS pain score >12, suggesting a neuropathic element to their pain. The early detection (using LANSS) and management of neuropathic pain using robust protocols represent the most effective strategy to address this significant problem.
Fluid Resuscitation: A Defence Medical Services Delphi Study into Current Practice
Authors: Wright C , Mahoney P , Hodgetts T , Russell R
Published: March 2013

A Delphi study was carried out to investigate recent changes in the fluid resuscitation of patients. A thirty member panel was selected primarily from the UK Defence Medical Services but also included contributors from other NATO members and civilian practice. The study was carried out in two rounds and achieved consensus on a range of statements relating to fluid resuscitation. Key recommendations are grouped by category. Statements reaching consensus included the use of adult intraosseous access, limited hypotensive resuscitation and goal directed therapy in trauma patients. Consensus was not achieved with respect to the selection of non-oxygen carrying synthetic colloids. The study provides a broad review of current practice and adds to previous consensus publications on fluid resuscitation.
A Complication of the use of an Intra-Osseous Needle
Authors: Fenton P. , Bali N , Sargeant I , Jeffrey SLA
Published: March 2013

Intraosseous needles provide an important alternative to intravenous access for administration of drugs, fluids and blood products in the emergency management of trauma patients. This case report highlights one potential complication of the use of one brand of IO needle.
Who Benefits from Intensive Care in the Field?
Authors: Birch K
Published: March 2013

The limited capacity and resources of a Field Hospital Intensive Care Unit may necessitate the triage or prioritisation of critically ill patients requiring admission. The use of critical care resources by members of the local population in certain Areas of Operation, who can not be discharged or transferred to equivalent care in their local health service, impacts significantly on bed occupancy. Therefore available resources must be distributed efficiently and equitably with decisions guided by the principles of advocacy for the patient. Patientsmust be admitted only on the concept of potential benefit and reasonable chance of recovery, which would not be available elsewhere. Discriminating between seriously ill patients before admission and decision making regarding withdrawal of care is very difficult. Senior clinicians working regularly in a critical care setting demonstrate a better level of discrimination in assessing outcome of seriously ill patients and are best placed to make decisions regarding admission, continuation and withdrawal of treatment.
Focus on Sepsis and Intensive Care
Authors: Johnston A McD
Published: March 2013

The Surviving Sepsis Campaign (SSC) Guidelines collate the evidence for managing sepsis. Most of the interventions suggested by the SSC guidelines are very relevant to military critical care, including rapid microbiologic investigation, early antibiotic administration and many aspects of early goal directed therapy. Other interventions may be more difficult to provide in remote theatres of operation where resources may be limited. This article discusses the application of the SSC guidelines to deployed military hospitals, with suggestions as to which interventions are feasible, and which may not be indicated.
Operational Critical Care. Intensive Care and Trauma
Authors: Shirley Peter
Published: March 2013

Trauma management involves good prehospital, emergency, surgical, anaesthetic and intensive care decision-making. Optimal outcome depends on keeping abreast of the latest thinking in an ever-changing and increasingly technology-rich environment. The intensive care unit needs to represented as early as possible in the damage-control resuscitation phase. Improved trauma system care has resulted in an increasing number of multiply injured military patents surviving their initial trauma. These patients require intensive care and are at risk from sepsis and multiple organ failure. Attention to detail is important, preservation of organ function, infection control and nutrition to maintain muscle strength allowing normal metabolic function to return. Multiply injured patients often require lengthy periods of mechanical ventilation and a variety of therapeutic interventions may have to be considered during management of the disease process. As we are now seeing more survivors in the military trauma system the focus now needs to be morbidity reduction in order for these survivors to be best prepared for their rehabilitation phase of care.
Neurointensive Care
Authors: Ralph J K , Lowes T
Published: March 2013

The majority of neurological admissions to military Intensive Care will be for Traumatic Brain Injury (TBI). These injuries will be either penetrating from fragmentation or missiles or blunt due to blast or impact. Intensive Care management of TBI is focused on the prevention of secondary brain injury due to insults such as hypoxia, hypotension and low Cerebral Perfusion Pressure. This management is based largely on comprehensive evidence based guidelines produced by the Brain Trauma Foundation. The most significant dilemma faced by UK military intensivists is whether we should be measuring Intracranial Pressure in patient with severe TBI in the deployed setting; and if so what technique should be used.
Improvised Skeletal Traction in the Management of Ballistic Femoral Fractures
Authors: Boyd MC , Mountain AJC , Clasper JC
Published: March 2013

Penetrating limb injuries are common during conflict, and in many there will be an associated fracture. Treatment of ballistic femoral fractures would usually be with by intramedullary nail; however, within the resource-constrained environment during conflict this is rarely possible. This report illustrates what can be achieved at a Role 2 facility to provide skeletal traction with the equipment and skills available. We discuss the history of skeletal traction and its use in ballistic femoral fractures, and believe that skeletal traction is still a valuable technique that we shouldn’t ignore. Military surgeons should be able to use skeletal traction to manage ballistic femoral fractures in the spartan environment of a deployed forward hospital.
Optimal Clinical Timelines - A Consensus from the Academic Department of Military Surgery and Trauma
Authors: Tai NRM , Brooks A , Midwinter M , Clasper JC , Parker PJ
Published: March 2013

There are no published studies directly addressing the issue of what is an acceptable timeline from point of wounding to surgical intervention within the military context. The proximal threshold has previously been determined by personal opinion, tactical, logistic and practical imperatives rather than by clinical demands. The aimof this paper is to review all relevantmilitary and civilian studies where timelines have been quoted and to reach a number of unambiguous consensus statements to state the perceived ideal upper limits from point of wounding to holistic and realistic surgical care in modern war.

An injured casualty should be transferred to an appropriate surgeon in an appropriate facility in as short a time from wounding as practical. It is clear that the best trauma surgery is performed in large, well resourced, well-supplied, airconditioned hospitals. Current advances aimed to stretch timelines from wounding to surgical intervention are exciting and hold potential but remain scientifically unproven and are currently without any firm evidence base. Further critical research is therefore necessary.

The effect of pre-hospital haemostatic resuscitation, provided by the enhanced Medical Emergency Response Team (MERTe) on patient outcome and effective timelines is currently unknown and unproven: it does have intuitive medical merit. There is also a very significant moral and morale component. MERTe serves two main functions; reduction in time from point of wounding to advanced / haemostatic resuscitation and provision of in-flight diagnostics. Continuation of in-flight resuscitation then allows physician-led decision making on critically unstable casualties. This allows either an expedited straight move from the HLS direct to the operating theatre or direct transfer to a regional neurosurgical centre. To prevent avoidable death, our unequivocal conclusion is that there must be an upper limit of 2 hours from wounding to surgical intervention (surgical haemorrhage control) for all casualties.
Improvised Explosive Devices: Pathophysiology, Injury Profiles and Current Medical Management
Authors: Ramasamy Arul , Hill AM , Clasper JC
Published: March 2013

The Improvised Explosive Device (IED), in all its forms, has become the most significant threat to troops operating in Afghanistan and Iraq. These devices range fromrudimentary homemade explosives to sophisticated weapon systems containing high-grade explosives. Within this broad definition they may be classified as Roadside explosives and blast mines, Explosive Formed Pojectile (EFP) devices and Suicide bombings. Each of these groups cause injury through a number of different mechanisms and can result in vastly different injury profiles.

The “Global War on Terror” has meant that incidents which were previously exclusively seen in conflict areas, can occur anywhere, and clinicians who are involved in emergency trauma caremay be required tomanage casualties fromsimilar terrorist attacks. An understanding of the types of devices and their pathophysiological effects is necessary to allow proper planning of mass casualty events and to allow appropriate management of the complex poly-trauma casualties they invariably cause. The aim of this review article is to firstly describe the physics and injury profile from these different devices and secondly to present the current clinical evidence that underpins their medical management.
The Battle of Keren - Medical support in a complex environment
Authors: Yates A
Published: March 2013

Rapid developments of capability seen in the contemporary operating environment are a constant during any period of conflict. The Second World War is littered with numerous examples of adapting systems developed following the First World War and making them more suitable for a more mobile, modern form of warfare. The East African campaign during 1941 saw a number of developments to an accepted field medical system. Established as a neat, linear structure from point of wounding through to hospital care, it was adapted to support a battle waged in a complex environment. The Battle of Keren, in Eritrea, was the decisive battle of the East African campaign, and is a remarkable example of rapidly exploiting success, with Commonwealth forces taking full advantage of Italian reluctance to become decisively engaged. To maximize success, support to the fighting echelon had to be, at least, as agile and able to adapt to circumstances presented resulting in the first significant land success of the war. It provided a vehicle for the Army Medical Services and Indian Army Medical Corps to develop a system of treatment and evacuation in an extremely challenging situation, a system that continues to have relevance today.
Back Pain in a Bangladeshi Worker in Iraq
Authors: White SH , Dickson S , Colman T , Hoque F , Boos Christopher
Published: March 2013

Pyogenic Spinal Infection (PSI) is an uncommon disorder encompassing a broad spectrum of diseases including septic spondylodiscitis, osteomyelitis, epidural and paravertebral abscess formation. Presentation can be vague and highly variable but usually includes back pain and fever. Whilst predisposing factors, such as trauma and diabetes can often be identified a pathogenic organism may not be identified in up to a half of all cases leading to significant delay in both accurate diagnosis and effective treatment. Precise spinal imaging is essential and includes plain X-ray, CT and preferably MRI. The treatment of PSI can be conservative (including antibiotics); however, spinal surgery may be required for the complications in up to 50% of cases, with varying degrees of success. We present a challenging case of PSI encountered in a locally-employed 42 year-old Bangladeshi civilian working in Iraq. Despite obvious resource limitations available within a Role 2 Field Hospital, clinical suspicion coupled with repeat spinal CT was pivotal in obtaining the diagnosis. The patient was repatriated to Bangladesh for MRI and definitive surgical treatment.
Self Assessment Questions in Ear, Nose & Throat Surgery
Authors: Masterson Liam , Banfield G
Published: March 2013

Ear, nose and throat conditions make up a large amount of a Medical Officer’s clinical workload. The examples given here illustrate some principles that should be employed when dealing with such problems.
A Personal View – 6 Months in a Fob
Authors: Cooper D J
Published: March 2013

General Duty Medical Officers (GDMOs) may deploy within days of completing their Entry Officers Course thereby missing the pre-deployment training undertaken by the Regiment that they join. They can be attached to a unit that they have never worked with and it is often the first time that they have worked in isolation. There is a steep learning curve both medically and militarily. GDMOs have to rapidly learn about medical resupply, environmental health, casualty evacuation and be prepared for the ethical and moral decisions they will have to make, especially when treating local nationals. This article describes the experiences of GDMOs from 16 Medical Support Regiment in Forward Operating Bases on Operation Herrick 8 in Helmand Province, Afghanistan. It aims to show that with careful thought and preparation future GDMOs can overcome any shortcomings in their pre-deployment training or difficulties they may face when working in a FOB.

This article is based on a presentation by the author at the Clinical Training Day Conference at the Permanent Joint Headquarters in November 2008.
Predisposing factors and associated symptomatology of British soldiers requiring a mental health assessment
Authors: Finnegan Alan , Finnegan S , Jackson C , Simpson R , Ashford R
Published: March 2013

Objectives

To critically evaluate the predisposing factors and symptomatology that resulted in serving officers and soldiers requiring a Mental Health (MH) assessment.

Methods

317 regular Army personnel who required a formal MH assessment completed a survey that detailed the predisposing factors and symptoms leading to the referral. SPSSv10 was used for data management and analysis of the data by descriptive and inferential statistical methods.

Results

Three quarter presented with at least two predisposing factors, the commonest being family issues (42%), relationship problems (40%) and general military stress (39%). Up to half of young male Soldiers required a MH assessment as a result of wanting to leave the Army, and were positively associated with self harming ideology. Female soldiers are significantly over represented. No-one reported feeling isolated.

Conclusion

The majority of personnel accessing the Army MH Services present with multi-factorial problems and symptoms that should result in colleagues being aware of their distress, and every effort must be made to support these soldiers within unit lines. That no one reported feeling isolated, challenges the perception that soldiers with MH problems are stigmatised. In those young male soldiers who wish to leave the Army there are indicators that significant periods of notice to leave can have a negative impact on MH. It is unclear why females are more likely to require support. If the emerging themes noted in this study are addressed, and the lessons learnt encapsulated within a predictive theoretical model, then the result could be an improvement in operational capability through the early return of Army personnel and Officers to full duty.
Management of Devastating Ocular Trauma - Experience of Maxillofacial Surgeons Deployed to a forward Field Hospital
Authors: Ansell Mark , J Breeze , VC McAlister , MD Williams
Published: March 2013

Combat-related eye injuries continue to increase in frequency and are generally secondary to Improvised Explosive Devices. Many ocular injuries are potentially preventable by the wearing of ballistic eye protection. The management of penetrating eye trauma is normally outside the routine practice of maxillofacial surgeons in the UK. The aim of this paper is to describe the surgical techniques used in the modern management of devastating ocular trauma including selected case examples managed by British military maxillofacial surgeons deployed to Afghanistan.
Traumatic Diaphragmatic Injury
Authors: Morgan BS , Watcyn-Jones T , Garner JP
Published: March 2013

Traumatic diaphragmatic injury is a not uncommon accompaniment to blunt or penetrating trauma to the abdomen or thorax; it may present acutely with haemodynamic and respiratory compromise and be associated with significant injury to other organs or may not be diagnosed at the initial trauma at all and present later as a diaphragmatic hernia. This overview examines the incidence, pathophysiology and management of this condition.
Anaesthetic and Critical Care Management of Thoracic Injuries
Authors: Round JA , Mellor Adrian
Published: March 2013

Thoracic wounding has been a relatively common presentation of military wounds throughout modern conflict. When civilian casualties are included the incidence has remained constant at around 10%, although the frequency and severity of wounds to combatants has been altered by modern body armour. Whilst thoracic injury has a high initial mortality on the battlefield, those surviving to reach hospital frequently have injuries that only require simple management. In addition to penetrating ballistic injury, blunt chest trauma frequently occurs on operations as a result of road traffic collisions or tertiary blast injury. The physiological impact of thoracic wounds, however, is often great and survivors often require intensive care management and, where available, complex strategies to ensure oxygenation and carbon dioxide removal. This review examines the incidence and patterns of thoracic trauma and looks at therapeutic options for managing these complex cases.
British Military Experience of Pre-Hospital Paediatric Trauma in Afghanistan
Authors: Walker N , Russell RJ , Hodgetts TJ
Published: March 2013

Introduction

Trauma is a leading cause of death in children. Life support courses have been developed to reduce the mortality and morbidity of children suffering trauma; differences in anatomy and physiology may produce different injury patterns to adults when children are exposed to trauma, challenging the care providers.

Methods

A retrospective analysis of all paediatric patients transported by the helicopter-borne MERT between 01 May 2006 and 31 December 2007 in Helmand Province, Afghanistan.

Results

78 children were brought in over the study period by the MERT team representing 7.3% of MERT casualties and 2.2% of the total seen in the Emergency Department. Breakdown by demographics, triage category, mechanism of injury, and treatment is given.

Conclusion

A significant number of paediatric patients are treated by the deployed pre-hospital team. All military pre-hospital care providers should gain training and experience in the care of the seriously injured child prior to deployment.
Advanced Airway Management – a Medical Emergency Response Team Perspective
Authors: Haldane Andrew
Published: March 2013

Objectives

To determine the number of medical emergency response team (MERT) patients undergoing advanced airway management in the peri-evacuation phase and to determine the indications for airway interventions undertaken in flight.

Methods

This was a retrospective study. Data was collected frompatient report andmission debrief forms completed after each MERT mission during Operation HERRICK 10 (April-October 2009). All patients that received advanced airway interventions before or during evacuation were identified.

Results

MERTs were involved in the primary transfer of 534 patients during the period studied, 56 (10.5%) underwent advanced airway management, of which 31 (5.8% of total) were initiated by the MERT in the peri-evacuation phase. Twenty five cases (4.7%) underwent advanced airway management by other pre-hospital providers prior to MERT arrival. Of the 31 advanced airway interventions undertaken in-flight, cardiac arrest was the primary indication in only nine cases.

Conclusions

The figure of 56 patients requiring advanced airway management is at the higher end of the range expected from the study of historicalmilitary data. Thismay reflect the doctrine of “intelligent tasking”, that is sending this physician-led teamto themost seriously injured casualties.
Preparing for an Operational Tour as a Medical Officer in Southern
Authors: Lyon J D , M Stacey , R Simpson
Published: March 2013

At the time of writing, Afghanistan is the pre-eminent theatre of operations for UK military forces, which form a lead element in the International Security Assistance Force. Many junior medical officers (MOs) can expect to see service on Operation HERRICK in the south of the country, in support of deployed battlegroup formations. MO’s will often find themselves supporting Company Group formations, either within the Company Aid Post , or on dismounted / vehicle borne operations. This article presents some of the challenges faced by those deployed in such circumstances, and proposes possible strategies to address them.
The General Practitioner Trainer Exchange as an Innovative Approach to Peer Review
Authors: van den Heuvel HGJ , Hood MP
Published: March 2013

There are various formal peer review schemes to assess the quality of primary care practices and several special approval and reapproval programmes exist for General Practitioner (GP) trainers and primary care training practices. The Defence Postgraduate Medical Deanery (DPMD) has its own General Practice Education Committee (GPEC) approval and re-approval programme. Part of this programme is related to the New Membership of the Royal College of Practitioners (nMRCGP). There is limited published information related to GP trainer exchanges as a means of peer review and as such as preparation for GPEC in the British Forces. This paper provides a review of a GP trainer exchange involving a visit of a GP trainer from British Forces Germany (BFG) to the practices of Dhekelia and Ay Nik on Cyprus in January 2010. It concludes that a GP trainer exchange is cost neutral andmay be a valuable experience for both the host and visiting GP trainer, the local GP trainers’ group, the practice teams and above all, for the GP trainee.
Swimming-Induced Pulmonary Oedema – A Hazard in Intensive Military Training?
Authors: Knutson Tina
Published: March 2013

Swimming-Induced Pulmonary Oedema (SIPE) has been described in military combat swimmers in both the US and Israeli Navies. The pathophysiology is explained by the immersion in cold water, and its effects on central vascular volume. SIPE has been hypothesized to be caused by pulmonary capillary stress failure (PCSF) due to elevations in pulmonary capillary transmural pressure. This leads to mechanical impairment and leakage of blood cells and proteins from capillaries. Patients with SIPE can present with pronounced dyspnoea, cough, hypoxemia and profuse frothy haemoptysis. Physical examination and chest X-rays usually show evidence of pulmonary oedema. The treatment of choice is to recognize the symptoms, get the patient out of the water and follow with close observation for emergent problems. Soldiers prone to acquire SIPE should be identified as this medical condition has a high degree of recurrence. The awareness of the symptoms of SIPE will increase appropriate diagnosis and therefore inform treatment.
Use of Transoesophageal Echocardiography during the Peri-operative Period for Trauma Patients
Authors: Smyth K , Hebballi R , Peterson MK
Published: March 2013

The medical facility at Camp Bastion continues to evolve as a consequence of the increased throughput of battlefield trauma patients. There is a requirement for rapid and accurate diagnosis of haemodynamic instability and continued haemodynamic monitoring throughout the peri-operative period. Transoesophageal echocardiography (TOE) has been used for this purpose in the arena of cardiac anaesthesia since the mid 1980s. It is being introduced to other peri-operative settings where severe haemodynamic instability is expected. The old proverb: ‘There are none so blind as those who cannot see’ (Jeremiah 5:21) is applicable to this topic, in that TOE is proven to be a rapid, portable, safe and effective tool in the assessment of the haemodynamically unstable patient. This paper explores the application of TOE for the assessment of the major causes of haemodynamic instability in the trauma population.
Research at High Altitudes
Authors: Mellor Adrian
Published: March 2013

Science and mountain exploration are closely linked throughout history. A large array of studies of varying complexity have been performed in conditions of hypobaric hypoxia, some on field studies, some in hypobaric chambers. The military has contributed greatly to this body of evidence both through operations in high altitude regions of the world, hypobaric chamber studies and through field studies as part of adventurous training expeditions. The hope is that by investigating hypoxia in fit participants in field or chamber studies insights may be gained into the adaptation to hypoxia during critical illness and novel approaches for treatment developed. Field studies in the mountains are challenging to design and undertake and need to balance practicalities (e.g. limited power supply) with scientific objectives. This article examines the history and rationale for high altitude research and discusses the challenges of organising a field study.
Respiratory Physiology at Altitude
Authors: Sandberg Claire , Naylor J
Published: March 2013

The changes in respiratory physiology that occur with increasing altitude are driven by the fall in the partial pressure of oxygen that occurs with decreasing barometric pressure. At altitude, respiratory system changes occur which impact on each step of the oxygen cascade that occurs within the body. These changes are pivotal to the process of acclimatisation to altitude. The study of human respiratory physiology at altitude has the potential to produce research that will be translational to disease states characterised by hypoxaemia.
Haematological Changes at Altitude
Authors: Wheatley K , Creed M , Mellor A
Published: March 2013

Hypobaric hypoxia is associated with an increase in erythropoesis and an increased thrombotic risk. This is true of long haul air travel, mountaineering expeditions and longer stays at altitude. Studies looking at clotting on mountaineering expeditions are further complicated by the effects of exercise, plasma volume changes and the catecholamine response to hypoxia. This review examines the evidence for changes in clotting factors and functional clotting at altitude and considers the implications of altitude travel for those with pre-existing medical conditions.
The Effect of High Altitude on the Visual System
Authors: Gibson Andrew , McKenna M
Published: March 2013

Increased ultraviolet light exposure and hypoxia at altitude along with the body’s physiological adaptation to altitude can lead to problems with the visual system. The problems that occur can be at the time of the exposure or delayed. The article provides an overview of the ways which the different components of the visual system can be affected following such exposure.
A Clinical Review of the Management of Frostbite
Authors: Grieve AW , Davis P , Dhillon S , Richards P , Hillebrandt D , Imray Chris
Published: March 2013

Frostbite is a thermal injury that can occur when temperatures drop low enough for tissue to freeze. On rewarming the tissues, an inflammatory process develops which is often associated with tissue loss. The extent of the tissue loss reflects the severity of the cold exposure and includes factors such as temperature, duration, wind chill, altitude, and systemic hypothermia.

This review discusses the epidemiology, the pathophysiological processes involved, and the clinical management of frostbite injuries. Practical advice is given on both the field and hospital management and how to seek expert advice from remote situations. The review also discusses newer developments in frostbite treatment such as intra-vascular thrombolysis and adjunctive treatments such as the use of intravenous vasodilators.