bluuebunny/crossref_metadata_2025 huggingface dataset:
Delayed Presentation of an Intra-Abdominal Arteriovenous Fistula
Authors: Davies ILL , Keightley G , Davies ML , Davies G , Dowdle RI , Lewis MH
Published: March 2013

This case report is the full report of the winning poster from the Military Surgery Conference 2008; abstracts of the best oral presentations are included later in this edition.
Performance Indicators for Prehospital Command and Control Developed for Civilian Use Tested in a Military Training Setting, A Pilot Study
Authors: Lundberg Lars , Jonsson A , Vikström T , Rüters A
Published: March 2013

Objectives

The aim of this study was to determine if a set of performance indicators for command and control (C2) primarily developed for civilian use could be applied also to a military training context as well.

Method

The initial decision-making in the on-scene medical management in a multinational military medical evacuation exercise in Afghanistan was studied, using this set of indicators.

Results

Two performance indicators were appropriate to this setting. Of the nine applicable indicators, the standards set for civilian use were met in four, in three other they were not met, and there was a lack of documentation in two indicators.

Conclusion

Measurable performance indicators for prehospital command and control were to some extent found to be applicable also to a military environment. Future developments may make it possible for the concept of measuring results using civilian performance indicators to become a quality control tool in a military setting.
Jejunal Lymphangioma Presenting as an Ovarian Mass
Authors: Norris Rory , Stacey M , Rampaul R S , Cheung K L
Published: March 2013

Intra-abdominal lymphangiomas are rare benign tumours that usually arise in the mesentery of the small bowel. We present the case of an intra-abdominal lymphangioma that involved both the jejunum and its adjacent mesentery that ultrasound and CT scanning suggested was an ovarian tumour. Laparoscopy confirmed normal ovaries and a jejunal mass which was resected at laparotomy. This circumstance has very rarely been described in the literature and represents a diagnostic dilemma of which clinicians should be aware. Intra-abdominal lymphangioma should be included with other non-gynaecological diseases in the differential diagnosis of a pelvic mass, and requires a multi-specialty approach.
Field Trauma Care in the 21st Century
Authors: O’Reilly David , König T , Tai N
Published: March 2013

The nature of trauma care on the modern battlefield is changing quickly. Leading figures in UK field trauma care spoke at a recent meeting of the Haywood Club. The challenge of modern warfare, the evolving evacuation chain and the command and governance of field trauma care were explored.
Emergency Thoracotomy – The Indications, Contraindications and Evidence
Authors: Morgan BS , Garner JP
Published: March 2013

Emergency thoracotomy is a dramatic and controversial intervention which may be life saving after major torso trauma. Success rates are variable and differ widely according to mechanism of injury. This article outlines the current indications and contraindications to emergency thoracotomy and examines the evidence to support it accumulated over 40 years.
Scoring Systems and Their Possible Use in a Military ICU Setting
Authors: Nutbeam T , O’Meara M , Henning J
Published: March 2013

Scoring systems for both trauma and intensive care patients have been widely used since the 1960’s. This article will introduce several scoring systems currently in use and discuss their potential use for military ICU patients.
Critical Care of Military Burn Casualties at Role 3 Facilities
Authors: Parkhouse Duncan
Published: March 2013

Burn casualties will inevitably occur in the military environment during both conflict and peacetime. The number and type of casualties will vary on the nature of warfare and the type of troops deployed. New preventative measures have decreased the number and severity of burns found on the battlefield however with new weapon systems casualties suffering from thermal injuries are still to be expected in modern warfare. Over the last 4 decades great advances have been made in the treatment of thermal injuries. These advances are reviewed here with emphasis on those that can be accomplished in the Role 3 facility by non-specialist clinicians. It is beyond the scope of this review to produce didactic treatment protocols but it is hoped that in the near future Clinical Guidelines for Operations will soon reflect these. Where advances have occurred that can not be mirrored in the field hospital early evacuation to specialist facilities back at Role 4 facilities should be a priority.
Critical Care Air Support Teams and Deployed Intensive Care
Authors: Turner S , Ruth M , Tipping Robert
Published: March 2013

The evacuation of injured patients by air has been going on in one form or another for nearly 100 years. This paper presents some of the history behind Aeromedical Evacuation (AE), the current situation and looks to the future of this vital component in the chain of care from point of wounding to rehabilitation.
Limb Complications following Pre-Hospital Tourniquet Use
Authors: Clasper J , Brown KV , Hill P
Published: March 2013

It has been stated that the application of a pre-hospital tourniquet could prevent 7% of combat deaths, however their widespread use has been questioned due to the potential risk from prolonged ischaemia. We reviewed members of the UK Armed Forces who sustained severe limb-threatening injuries in Iraq and Afghanistan, and performed a matched cohort study based on the presence or absence of pre-hospital tourniquet application. When a pre-hospital tourniquet had been applied, 19/22 patients had a least one complication compared to 15/22 where no tourniquet had been applied [p=0.13]. There were 10 limbs with at least one major complication in the pre-hospital tourniquet group but only four in the group with no tourniquet [p=0.045].

The significant difference in the incidence of major complications is a concern, particularly as the difference was mainly due to a deep infection rate of 32% vs. 4.5%. Although a number of variables could have influenced these small groups, such as choice of fracture fixation implant and method and timing of wound closure, the use of a matched cohort study design with a statistical significance level of p < 0.05, suggests the use of a pre-hospital tourniquet as a factor. Althoughthe use of pre-hospital tourniquets cannot be decried as a result of this study, the need to continually prospectively review their use to determine their risk/benefit ratio remains.
Prevention of Suicidal Behaviour among Army Personnel: A Qualitative Study
Authors: Crawford M. J. , Sharpe D , Rutter D , Weaver T
Published: March 2013

Objectives

To examine the context of suicidal behaviour among soldiers in the United Kingdom and identify factors that could reduce the risk of such behaviour.

Method

A series of in-depth interviews with service providers involved in treating soldiers following deliberate self harm. Their responses were compared with those of a small sub-sample of soldiers who presented to Army medical services following self harm.

Results

We interviewed 21 service providers with a range of experience and professional backgrounds and 10 soldiers. Service providers told us that the rarity of suicide among soldiers together with lower levels of mental illness amongst those who end their lives made suicide prevention in the Army a difficult task. However they highlighted concerns about recruitment and retention of young soldiers, and stated that stigmatisation of mental illness in the Army sometimes prevented those with suicidal ideation seeking help. They also highlighted the role of alcohol use in precipitating self-harm. Soldiers who had self-harmed told us that they struggled to balance the demands of work and family life and described harming themselves impulsively often while intoxicated with alcohol. Soldiers look to sources of support outside the Army, and see commanding officers, rather than healthcare professionals, as helping resolve their problems. Neither service providers nor soldiers mentioned helplines and other ‘independent’ sources of confidential advice and support which are available to soldiers serving with the British Army.

Conclusion:

Our findings highlight problems associated with efforts to reduce suicide among soldiers but suggest that these should focus continuing to try to reduce stigmatisation of mental distress and specifically on the role of commanding officers. Greater efforts should also be made to publicise existing sources of help and reduce levels of alcohol misuse.
Self Assessment Questions in General Surgery
Authors: Morgan J , Garner Jeff
Published: March 2013

The advent of Modernising Medical Careers has meant that many more junior doctors are coming into contact with general surgical patients either as part of Foundation Year 2 or Core Training rotation or during the course of cross covering other specialities due to the hours constraints of the European Working Time Directive. These scenarios are all common general surgical cases that such a junior doctor may be expected to manage.
Current Concepts in the Epidemiology and Management of Battlefield Head, Face and Neck trauma
Authors: Breeze John , Bryant D
Published: March 2013

There has been a significant increase in the incidence of head, face and neck (HFN) injuries in the 21st century in comparison to that experienced in the previous century. In the majority of HFN injuries the primary cause of death is secondary to airway compromise and with the exception of severe neck wounds haemorrhage is an unusual cause of death. Emergency cricothyroidotomy and semi- elective tracheostomy are skills that should be taught to deploying surgeons. There are now significantly increased numbers of potentially salvageable HFN injuries resulting from new and effective armour that protects the torso and abdomen. Equivalent armour to protect the neck and face is not yet effective and requires development. We describe the current epidemiology and management of battlefield head, face and neck trauma.
Assessment and outcome of 496 penetrating gastrointestinal warfare injuries
Authors: Saghafinia M , Nafissi N , Motamedi MHK , Motamedi MHK , Hashemzade M , Hayati Z , Panahi F
Published: March 2013

Aim

The abdominal viscera are among the most vulnerable organs of the body to penetrating trauma. Proper management of such trauma in war victims at the first-line hospital where these victims are first seen is of paramount importance. We reviewed medical records of war victims suffering small bowel and colorectal injuries treated at first, second and third-line hospitals during the Iraq-Iran War (1980-88) to assess surgical outcomes.

Methods

The medical records of 496 Iranian war victims suffering penetrating gastrointestinal (GI) injuries treated at first, second and third-line (tertiary) hospitals, a total of 19 centres, were reviewed. Laparotomy had been performed at the 1st line hospitals for all patients who had an acute abdomen, whose wounds violated the peritoneum or whose abdominal radiographs showed air or shrapnel in the abdominal cavity. Stable patients were transferred from first-line to second-line or from second line to tertiary hospitals postoperatively. The treatments, complications and patient outcomes were documented and analyzed.

Results

There were 496 patients; 145, 220 and 131 victims underwent laparotomy for GI injuries at first, second and third-line hospitals respectively. The small intestine and colon respectively were the most prevalent abdominal organs damaged. Those first treated for GI injuries at front-line hospitals (145 victims) had more serious conditions and could not be transferred prior to surgery and presented a higher prevalence of complications and mortality. Overall mortality from GI surgery was 3.6% (18 patients). Eleven patients (7.5%) whose first GI operation was performed at frontline hospitals and 7 patients (3.2%) who underwent their first surgical operation at second-line hospitals died. The most common reason for these deaths was complications relating to the gastrointestinal operation such as anastomotic leak. Six missed injuries were seen at the frontline and one at second line hospitals. There were no deaths at the 3rd line hospitals.

Conclusion

Penetrating abdominal injuries were common in Iranian victims of war often causing multiple organ injuries. The colon and small intestine were the more commonly injured organs and carried the most postoperative complications. Mortality at 1st line hospitals was more than double that of 2nd line hospitals; the complication rate was also greater as was the number of missed injuries. Adherence to the standard surgical protocols, prompt evaluation, proper triage and management are factors which may lower patient morbidity and complications.
Simulation training for the Frontline- realistic preparation for Role 1 doctors
Authors: Mercer Simon J , Howell M , Simpson R
Published: March 2013

Simulation in Healthcare is gaining popularity worldwide. Recently it has been decided that there should be a simulation component to pre-deployment training for doctors destined for Role 1. Little is known about the challenges, workload, case mix and non-technical issues that face medical personnel working out of a Forward Operating Base. To examine this further, a workshop was convened with subject matter experts and simulation trainers. Common themes identified were concerning predeployment issues, team working, evaluation prior to transfer, equipment, communication and specific clinical issues. Six scenarios were developed over the course of the day that included desired learning objectives in form of technical and nontechnical skills. There are many aspects of team resource management or non-technical skills already researched that can be transferred directly into a Role 1 healthcare setting. Simulation offers the chance to provide training in a safe and controlled environment and can potentially ensure specific defined learning outcomes are achieved. This article reports the first steps in the process of providing this new type of training and discusses the faculty requirements, the available methods of delivery and specific issues surrounding fidelity.
The Clients’ Perspective – Do military uniform and rank impact on the therapeutic relationship between military mental health clients and clinicians
Authors: Wilson MM , McAllister PD
Published: March 2013

Objective

To measure the perception of military mental health clients of the impact of wearing military uniform on the therapeutic relationship between client and clinician and to ascertain if uniform and rank is perceived as a barrier.

Method

A brief questionnaire was distributed to Departments of Community Mental Health to be disseminated to theirmental health clients to measure their responses.

Results

282 responses from mental health clients were collected over a 30 day period regarding the impact that military uniform makes to the therapeutic relationship with the clinician. 63%(n=178) regarded uniform as negatively influencing their relationship with the clinician, 37% (n=104) responded that it did not. 39% (n=111) believed rank to be a barrier, whereas 61% (n=171) did not believe it affected the relationship.

Conclusion

The majority of military mental health clients regard the wearing of uniform as negative to the therapeutic relationship and a significant minority have similar feelings about rank. Military mental health practitioners should consider the impact of these results on the therapeutic relationship with military patients.
Secondary Abdominal Compartment Syndrome after Military Wounding
Authors: Lamb C M , Berry JEA , DeMello WF , Cox C
Published: March 2013

Intra-abdominal hypertension and abdominal compartment syndrome are increasingly recognised as causes of serious morbidity andmortality in critically injured patients, particularly those with significant burns. Identification of at risk patients, routine monitoring of intra-abdominal pressures and appropriate, early treatment may reduce the incidence and complication rate of abdominal compartment syndrome and so improve outcomes in critically injured personnel. We present the case of an American Marine injured in an explosion while on patrol in Afghanistan, who despite the absence of significant intraabdominal injury, went on to develop abdominal compartment syndrome and required decompressive laparotomy.
Clinical Strategies in the Management of Complex Maxillofacial Injuries Sustained by British Military Personnel
Authors: McVeigh Kieron , J Breeze , P Jeynes , T Martin , S Parmar , AM Monaghan
Published: March 2013

The maxillofacial injuries sustained by British troops requiring aeromedical evacuation to the United Kingdom are almost exclusively treated at The Royal Centre for Defence Medicine in Birmingham. As a result the Maxillofacial Department has collectively gained extensive experience in the management of ballistic injuries. In many cases the most successful outcomes have been achieved by using traditional strategies combined with contemporary techniques. This paper will highlight the types of injuries sustained and discuss some cases that typify those the department has managed.
UK Role 4 Military Infectious Diseases at Birmingham Heartlands Hospital in 2005-9
Authors: Glennie JS , Bailey Mark S
Published: March 2013

Objectives

Infectious diseases affecting British troops are mostly due to gastrointestinal and respiratory illnesses, but these are usually minor in severity, easy to manage and short in duration. To assess the importance of infections that are more severe, difficult to manage or longer in duration, it is necessary to look at military cases that are evacuated or otherwise referred to the UK Role 4 (definitive care) medical facility for infectious diseases.

Methods

Case notes from military infectious disease patients seen at Birmingham Heartlands Hospital in 2005-2009 were reviewed to extract data on demographics, origin of infection, diagnostic categories, exact diagnoses, type and duration of care, time off duty, quality of care and costs incurred.

Results

Over a 4-year period, 138 cases were referred, 131 (95%) were male and 98 (71%) were from the Army. The origin of infection was Afghanistan in 52 (38%) and Belize in 19 (14%). From 131 patients (95%) that attended, 59 (45%) had dermatological illnesses and 38 (29%) had undifferentiated febrile illnesses. Diagnoses included 35 (27%) with cutaneous leishmaniasis and 21 (16%) with “Helmand Fever” due to sandfly fever, acute Qfever or rickettsial infection. For 51 in-patients, the median (range) length of stay was 3 (1-17) days and time off duty was 20 (5-127) days. For 80 out-patients, the median (range) number of attendances was 1 (1-23) and time off duty was 22 (1-228) days. All cases were seen promptly (within 7 days for in-patients and 28 days for out-patients), but only 59 (45%) had appropriate letters sent to the referring medical officer and none had FMed 85 notifications of infectious disease submitted. Aeromedical evacuation costs could not be calculated, but UK hospital care cost ∼ £ 78 000 per year.

Conclusions

Dermatological infections and undifferentiated febrile illnesses that require management at a UK Role 4 facility are important causes of disease non-battle injury. Prospective collection of this data in the future will be a valuable asset.
Force Generation – Deployment-aligned MIACs
Authors: Colvine A
Published: March 2013

As the pressure mounts to supply more ground forces in Afghanistan, the Defence Medical Services (DMS) are directly supporting surge activity through ensuring the provision of deployable personnel. Delivery of this goal requires a change in the practice, focus and resources of the DMS. Identification, treatment and rehabilitation of injured service personnel is a priority in improving the pool of personnel available for deployment on Operations. This paper details the drivers, process and potential benefits of aligning Multi-Disciplinary Injury Assessment Clinic’s activity with a unit’s formation readiness cycle, to more appropriately and proactively manage injured service personnel to improve both the quality and quantity of Force Generation.
Cardiology
Authors: Boos Christopher , Cox AT
Published: March 2013

Cardiac disease remains a significant threat to both local and deployed military populations. In this article we present several cardiac case reports which may be of educational use to the military clinician.
The Army Primary Health Care Service: From Foundation to Future
Authors: Burgess Col J
Published: March 2013

Following the British Government’s implementation of policies to improve quality and introduce clinical governance into healthcare delivery in the late 1990s, the British Army commissioned a study into how primary healthcare for the Regular Army should best be delivered in UK. The study recommended a unitary command structure, with more central control based upon a model of a main headquarters and seven regions. The change has been largely successful and has been subject to external scrutiny. Areas still to be developed include improving information management and benchmarking standards against the NHS, improvements in practice management, plus developments in occupational health and the nursing cadres. The forthcoming Strategic Defence and Security Review and other ongoing studies are likely to have a profound influence on how the current Army Primary Health Care Service develops.
The Effectiveness of an Informal Teaching Programme for Junior Doctors Identifying Pleural Effusions Using Ultrasound at the Bedside
Authors: Moy Ross J , Chapman AL , Bapusamy A
Published: March 2013

Objectives

The use of bedside ultrasound to localise pleural effusions has gained in popularity in recent years. We investigated whether or not junior doctors could accurately identify thoracic anatomical structures and localise pleural effusions using bedside ultrasound.

Methods

Junior doctors were instructed by a consultant chest physician in the theory and practice of using ultrasound to localise pleural effusions, and then instructed in the method of inserting a Seldinger chest drain. Juniors were instructed to record a scan picture, including labelling of relevant structures. We then conducted a review of 52 images, noting indications, complications and the grade of doctor performing the scan. A consultant radiologist reviewed the scan pictures to confirm that the anatomy was correctly identified.

Results

Fifty out of 52 images (96%) were of diagnostic quality, with the anatomy correctly identified. The complication rate from chest drain insertion was 3.85%.

Conclusions

With instruction, junior doctors can competently utilise basic chest ultrasound, obtain useful images, identify relevant thoracic anatomy and insert chest drains by the Seldinger technique with a low rate of complications. We suggest thoracic ultrasound should be more widely taught to junior doctors.
Furosemide in the Treatment of Phosgene Induced Acute Lung Injury
Authors: Grainge C , Smith Adam , Jugg BJ , Fairhall SJ , Mann T , Perrott R , Jenner J , Millar T , Rice P
Published: March 2013

Method

Using previously validated methods, 16 anaesthetised large white pigs were exposed to phosgene (target inhaled dose 0.3 mg kg-1), established on mechanical ventilation and randomised to treatment with either nebulised furosemide (4 ml of 10 mg.ml-1solution) or saline control. Treatments were given at 1, 3, 5, 7, 9, 12, 16 and 20 hours post phosgene exposure; the animals were monitored to 24 hours following phosgene exposure.

Results

Furosemide treatment had no effect on survival, and had a deleterious effect on PaO2: FiO2ratio between 19 and 24 hours. All other measures investigated were unaffected by treatment.

Conclusion

Nebulised furosemide treatment following phosgene induced acute lung injury does not improve survival and worsens PaO2: FiO2ratio. Nebulised furosemide should be avoided following phosgene exposure.
Anaesthesia at Role 4
Authors: Wood Paul , Haldane AG , Plimmer SE
Published: March 2013

The contribution of anaesthesia to the care of injured military personnel at Role 4 is described with particular emphasis on the working relationship between the Royal Centre for Defence Medicine and the civilian department of anaesthesia. The implications for operating theatre activity are discussed.
Critical Care at Role 4
Authors: Jones CPL , Chinery JP , England K , Mahoney PF
Published: March 2013

This descriptive paper focuses on the sequence of events that occur during the admission and ongoing management of the Military Polytrauma patient to Critical Care, Area B, Queen Elizabeth Hospital Birmingham (QEHB). It is intended to inform new clinical staff, the wider DMS, and potentially other NHS intensive care units which may be called upon to manage such patients during a military surge or following a UK domestic major incident.
Vascular Access on the 21st Century Military Battlefield
Authors: Hulse Elspeth J , Thomas GOR
Published: March 2013

Timely and appropriate access to the vascular circulation is critical in the management of 21st century battlefield trauma. It allows the administration of emergency drugs, analgesics and rapid replacement of blood volume. Methods used to gain access can include; the cannulation of peripheral and central veins, venous cut-down and intraosseus devices. This article reviews the current literature on the benefits and complications of each vascular access method. We conclude that intraosseus devices are best for quick access to the circulation, with central venous access via the subclavian route for large volume resuscitation and low complication rates. Military clinicians involved with the care of trauma patients either in Role 2 and 3 or as part of the Medical Emergency Response Team (MERT), must have the skill set to use these vascular access techniques by incorporating them into their core medical training.
Cardiac Arrhythmias at High Altitude
Authors: Woods David , Boos C , Roberts PR
Published: March 2013

Palpitations at high altitude have been experienced, but seldom recorded, for centuries. The hypoxia, sympathetic activation and alkalosis of altitude predispose to cardiac ischaemia and arrhythmia. Indeed, sudden cardiac death is responsible for 30% of all deaths during mountain sports at altitude. This article reviews the literature to date on the evidence for cardiac arrhythmias at altitude.
Prolongation of the Corrected QT Complex – A Cause of Sudden Cardiac Death in the Mountain Environment?
Authors: Windsor J S , Rodway GW , Mukherjee R , Firth PG , Shattock M , Montgomery HE
Published: March 2013

In the mountain environment sudden cardiac death (SCD) has been shown to be responsible for the deaths of up to 52% of downhill skiers and 30% of hikers. The majority of SCD’s are precipitated by a ventricular arrhythmia. Although most are likely to result from structural abnormalities associated with conditions such as ischaemic heart disease, a small but significant number may be due to abnormalities in ion channel activity, commonly known as, “channelopathies”. Channelopathies have the potential to lengthen the time between ventricular depolarisation and repolarisation that can result in prolongation of the corrected QT interval (QTc) and episodes of polymorphic ventricular tachycardia (PVT) and eventually, ventricular fibrillation. This review examines the factors that prolong the QTc interval in the mountain environment and outlines a practical framework for preventing the life threatening arrhythmias that are associated with this condition.
Exped 2010 – The Challenges of an Expedition Doctor
Authors: Williams Katie
Published: March 2013

‘Exped 2010’, a climbing and trekking expedition to the Everest region of Nepal, marked the 150th anniversary of the Army Cadet Force, during October 2010. A team of 20 cadets aged 14-18 years together with a combination of adults, mountain leaders and the expedition doctor, completed the trek to Everest Base Camp with a small number summiting Island Peak. The junior team, consisting of younger members aged 14-16 years, were limited to sleeping at a maximum altitude of 4240m but nevertheless, achieved a trekking altitude of 5000m. Over the three week period, there were a number of challenges for the expedition doctor - integrating into the team, finding time to rest and acclimatise along with the others whilst dealing with over 35 consultations, numerous cases of traveller’s diarrhoea, several helicopter evacuations and also managing cases of altitude illness both within the group and for several foreign trekkers along the way.
Challenges Faced by British Military Ophthalmic Services During the First World War
Authors: Whitaker John
Published: March 2013

The First World War was a time of great change for many areas of military medicine. This article reviews some of the particular challenges faced by British Ophthalmic Services during 1914-18
Septic Arthritis as a Presentation of Crohn’s Disease
Authors: Zaidi Razi , Dala-Ali B , Dalton DJN
Published: March 2013

A 42 year old man with colonic Crohn’s disease presented to the orthopaedic department with septic arthritis of the knee with frank intra-articular pus, which persisted despite repeated joint washouts. This coincided with a symptomatic flare of his colonic Crohns. Imaging revealed a fistulous connection from the proximal sigmoid colon into the pelvis, a psoas abscess, myositis of the musculature around the left pelvic girdle and left thigh and two focal collections almost surrounding the distal femur. The knee symptoms only settled after laparotomy and resection of the diseased sigmoid colon and fistula. This case report demonstrates an unusual presentation of fistulating Crohns disease as septic arthritis.
Consensus Statement on Decision Making in Junctional Trauma Care
Authors: Parker P
Published: March 2013

Improvised explosive devices (IEDs) cause 60% of all UK fatalities in the current campaign in Afghanistan. Shorter evacuation timelines now deliver patients at the edge of the physiological envelope of survivability meaning that the available time period for haemorrhage control and initial wound surgery is short – often no more than 75 minutes. The concepts and practise of ‘right turn resuscitation’, damage control general and orthopaedic surgery, on-table ‘ITU’ pause/catch-up and then further resuscitative surgery are commonplace. In Helmand in 2011, multiple team operating is now the norm on these casualties with up to seven surgeons and three anaesthetists simultaneously involved in the operative care of one patient. This usually involves one consultant orthopaedic surgeon and trainee per lower limb, a plastic surgeon on the upper limb or face/eyes and two general surgeons obtaining proximal vascular control or in-cavity haemorrhage control. A combined meeting in 2010 of the Lower Limb and Torso Trauma Working Groups of the Academic Department of Military Surgery and Trauma produced 25 clear, didactic statements to provide advice to the consultant team. The fundamental message is that bleeding is always a surgical problem. Some adjuncts are available; pressure (direct and indirect), compressive bandaging, haemostatic dressings and tourniquets. However, only formal surgical control, by whatever means is definitive. Early proximal control is mandatory: in all cases, rapidly obtain the most distally appropriate proximal control above the zone of injury.
Making Difficult Decisions in Major Military Trauma: A Crew Resource Management Perspective
Authors: Midwinter MJ , Mercer S , Lambert AW , Rond MJ de
Published: March 2013

The purpose of this article is to consider three underappreciated but important features of high performance teams: the trade-off relation between social and technical competence, the relevance of team size on productivity, and the inevitability of tensions that, while often experienced as dysfunctional, are in fact quite useful. It does so by reviewing a series of related studies in aviation and the organisation sciences, and by extrapolating insights for crew resource management in major military trauma along two generic themes: team context and team process.
Management of Intestinal Injury in Deployed UK Hospitals
Authors: Fries Cdr Anton , Penn-Barwell J , Tai NRM , Hodgetts TJ , Midwinter MJ , Bowley DM
Published: March 2013

Introduction

Definitive laparotomy (DL), with completion of all surgical tasks at first laparotomy has traditionally been the basis of surgical care of severe abdominal trauma. Damage control surgery (DCS) with a goal of physiological normalisation achieved with termination of operation before completion of anatomical reconstruction, has recently found favour in management of civilian trauma. This study aims to characterise the contemporary UK military surgeon’s approach to abdominal injury.

Patients and methods

A retrospective analysis was performed on British service personnel who underwent a laparotomy for intestinal injury at UK forward hospitals from November 2003 to March 2008 as identified from the Joint Theatre Trauma Registry. Patient demographics, mechanism and pattern of injury and clinical outcomes were recorded. Surgical procedures at first and subsequent laparotomy were evaluated by an expert panel.

Results

22 patients with intestinal injury underwent laparotomy and survived to be repatriated; all patients subsequently survived to hospital discharge. Mechanism of injury was GSW in seven and blast in 13. At primary laparotomy, as defined by the operating surgeon, 15/22 underwent DL and 7/22 underwent DCS. Mean Injury Severity Score (ISS) was 19 for DL patients compared to 29 for DCS patients (p=0.021). Of the 15 patients undergoing DL nine had primary repair (suture or resection / anastomosis), one of which subsequently leaked. Unplanned re-look was required in 4/15 of the DL cases.

Conclusion

This review examines the activity of British military surgeons over a time period where damage control laparotomy has been introduced into regular practice. It is performed at a ratio of approximately 1:2 to DL and appears to be reserved, in accordance with military surgical doctrine, for the more severely injured patients. There is a high rate of unplanned relook procedures for DL suggesting DCS may still be underused by military surgeons. Optimal methods of selection and implementation of DCS after battle injury to the abdomen remain unclear.
A Brief History of War Amputation
Authors: Kinch Kevin , Clasper JC
Published: March 2013

Throughout the history of warfare, changes in weaponry have produced changes in the nature of war injury. The 16th century saw the introduction of firearms in conventional warfare, bringing the destructive power of weaponry to new and unseen heights with a dramatic increase in the severity and complexity of battle injuries. Destructive gunshot wounding associated with embedded foreign material often led to sepsis and demanded the more radical treatment of amputation. Over the past 500 years innumerable developments have taken place in anaesthesia, asepsis, transfusion therapy and resuscitation, antibiotic therapy, vascular surgery and wound management. Medical services have had to adapt in order to cope with the changing volume and changing nature of battle casualties resulting from modern weaponry. Despite the progress made, amputation is still a commonly performed operation following traumatic limb injury. In those cases where the decision to amputate is not so clearly and distinctly defined, history has shown that prevention of infection requires aggressive primary surgery and removal of all devitalised tissue. This paper examines the history of amputation in the management of the battlefield casualty suffering limb injury, beginning in the 16th century and continuing into present day.
Use of Hearing Protection on Military Operations
Authors: Patil Mangala , Breeze J
Published: March 2013

Noise Induced Hearing Loss (NIHL) continues to be a significant source of morbidity for UK service personnel. The Personal Interfaced Hearing Protection (PIHP) system was procured as an Urgent Operational Requirement primarily to provide a connection to the Personal Role Radio. Through its custom- mould design it was also expected to act as Personal Protective Equipment (PPE) against NIHL in a method that had not been possible previously. The aim of this paper was to evaluate user opinion of the four current methods of hearing protection including PIHP. 108 service personnel serving in a Forward Operating Base in Afghanistan were questioned anonymously using a paper-based questionnaire. The response rate was 78%, reflecting the difficulties in anonymous data collection in an environment such as this. PIHP was perceived to be more practical for use on the ranges or patrolling than the standard methods of hearing protection. Although only 4% were routinely wearing PIHP on patrol, this was related to understandable reluctance in wearing a new system that had only been issued immediately prior to this deployment. Early design problems highlighted by our study, such as changes in the design of the ear-piece to improve retention, have already been implemented. Compliance will be improved through a dedicated educational programme to explain its relevance. Despite the logistical difficulties in providing custom- made ear moulds, the PIHP system must be delivered to all service personnel early in their career so they are confident in its use long before operational deployment. Future research is required to ascertain the effectiveness of PIHP as a method of PPE in reducing the incidence of NIHL.
General Duties Medical Officer With the British Forces in Cyprus
Authors: Bennett Britton T M
Published: March 2013

The aim of this article is to describe the role and training of a General Duties Medical Officer (GDMO) based with the British Forces in Cyprus.
Don’t Forget The Fragment! An Unusual Case of Occult Fragment Embolisation Following Penetrating Neck Injury
Authors: Davies Emma , Boylan M , Hawker JJ , Banerjee B
Published: March 2013

Fragment embolisation following vascular injury is uncommon. The case of a 31 year old soldier, who sustained a penetrating fragment injury to the neck with distal arterial embolisation, is presented and the discussion illustrates both the importance of expedient assessment and management of cervical vascular injuries and of thorough correlation of clinical and radiological findings to avoid missed emboli.
A Pre-hospital Technique for Controlling Haemorrhage from Traumatic Perineal and High Amputation Injuries
Authors: Quayle JM , Thomas GO Rhys
Published: March 2013

Perineal trauma resulting from the adaptive use of improvised explosive devices (IEDs) has become an increasingly common problem during current operational conflicts in Afghanistan. Control of haemorrhage from the perineum and high amputations is a particular challenge due to the bony anatomy, rich pelvic vascular supply and the difficulty in achieving haemostasis by direct pressure. In this article, the authors describe a potential pre-hospital solution for controlling haemorrhage from perineal and high amputation injuries.
The Influence of Perceptions and Beliefs of Civilian Physiotherapist Working for the Ministry of Defence in their Management of Back Pain: An Exploratory Study using Mixed Methods
Authors: Bond SJ , Soundy A
Published: March 2013

Background

There is a high prevalence of Lower Back Pain (LBP) within military populations. Physiotherapeutic management has a primary role for patient care, but there is a need to establish the most effective management. Civilian physiotherapists provide the majority of clinical provision throughout the Defence Medical Rehabilitation Programme for British Armed Forces personnel. To date no study has been carried out looking at their perceptions and beliefs with regards to management of non-specific LBP and the potential impact this had on the delivery of rehabilitation across Defence.

Methods

This mixed methods exploratory study aimed to explore the potential complexities surrounding the decision making process with regards to management of non-specific LBP using semi-structured interviews with 14 MOD civilian physiotherapists. All interviews were transcribed verbatim. The transcribed data was then subjected to a categorical content analysis.

Results

The analysis of the interview data revealed four interrelated themes that influence civilian physiotherapists in their management of back pain in military personnel: the military environment, integration of military procedures, physiotherapist treatment approach and communication.

Discussion

This paper highlights the value civilian physiotherapists place on experience when managing non-specific LBP. This experience however was gained through ‘patient mileage’ rather than integration of best evidence into practice. Several problems were identified in patient management including specific types of patients and their expectations and the importance of the right communication between Health Care Professionals, but also with patients.
Anti-Malarial Chemoprophylaxis Following Evacuation from Afghanistan
Authors: Keene DD , Tong JL , Roughton S , Fadden SJ
Published: March 2013

UK forces deployed to Afghanistan between March and November are prescribed anti-malarial chemoprophylaxis (AMC). In 2007 an audit showed poor pre-injury AMC compliance and a prescription rate of 50% amongst those casualties evacuated to Role 4. We re-audited the post-deployment AMC prescribing practice for casualties from Afghanistan for the 2008 and half of the 2009 malaria season. Using the Role 4 prescribing information and communication system (PICS), a retrospective AMC search for Proguanil, Chloroquine, Doxycycline, Mefloquine and Malarone was performed on these casualties. Only five out of 305 (1.64%) inpatients were prescribed appropriate post-deployment AMC medication. Awareness of the need to prescribe AMC following evacuation remains poor, and may be improved by recording AMC compliance in field medical records and modifying the PICS software.
Hereditary Neuropathy with Liability to Pressure Palsies Occurring During Military Training
Authors: Delacour Hervé , Bompaire F , Biale L , Sallansonnet-Froment M , Ceppa F , Burnat P
Published: March 2013

Hereditary neuropathy with liability to pressure palsies (HNPP) is an autosomal-dominant peripheral neuropathy characterized by recurrent isolated nerve palsies, which are precipitated by trivial compression and trauma. Although HNPP has been well-described in literature, it often goes unrecognized. We report a case of HNPP occurring during military training to promote recognition and proper management of this entity.
Simple Posterior Elbow Dislocation and Brachial Artery Transection
Authors: Thomas Lee Graham , Williams DT
Published: March 2013

We report the uncommon occurrence of a complete brachial artery transection following simple posterior dislocation of the elbow, successfully managed by cephalic vein interposition grafting. This case together with a review of the literature was conducted with the aim of highlighting important issues regarding the diagnosis, management and prognosis of this rare complication.
Spinal Fractures in Current Military Deployments
Authors: Eardley Will , Bonner TJ , Gibb IE , Clasper JC
Published: March 2013

Objective

To describe spinal fracture patterns presenting to deployed medical facilities during recent military operations.

Methods

Retrospective analysis of the United Kingdom Centre for Defence Imaging Computed Tomography database, 2005- 2009. Fractures are classified, mechanism noted and associated injuries recorded. Statistical analysis is by Fisher’s Exact test.

Results

128 fractures in 57 casualties are analysed. Ballistic (79%) and non-ballistic mechanisms contribute to vertebral fracture at all regions of the spinal column in patients treated at deployed medical facilities. There is a high incidence of lumbar spine fractures, which are more likely to be due to explosion than gunshot wounding (p<0.05). Two thirds of thoracolumbar spine fractures caused by explosive devices are unstable and are mainly burst-fractures in configuration. 60% of spinal fracture patients had concomitant injuries. There is a strong relationship between spinal fractures caused by explosions and lower limb fractures.

Conclusion

Injuries to the spine caused by explosive devices account for greater numbers, greater associated morbidity and increasing complexity than other means of spinal injury managed in contemporary warfare. With the predominance of explosive injury in current conflict, this work provides the first detail of an evolving injury mechanism with implications for injury mitigation research.
The Skeleton Coast Diet Plan: Body Mass and Body Fat Changes on an Arduous Expedition
Authors: Nicol Alastair , Donoghue O
Published: March 2013

Objectives

No one has ever walked the 500 Km Skeleton Coast of Namibia totally unsupported. Fourteen explorers overcame this by carrying, along with all their other equipment, hand-held pumps to desalinate sea water on a daily basis to produce sufficient potable water. This paper highlights the changes in body mass, waist circumference and body fat in the group on this unique 20 day expedition.

Methods

Eight males (mean (SD)) 42.3 (9.7) years, height 1.741 (0.043) m, weight 78.7 (8.6) kg, body mass index (BMI) 24.8 (2.0) kg/m2) and six females (mean (SD) 40.0 (5.3) years, height 1.628 (0.043) m, weight 63.2 (5.5) kg, BMI 23.8 (1.8) kg/m2) undertook the expedition. Average pack weight at the start of the expedition for the men was 32.5 kg, and 26.5 kg for the women. On most days, the team walked for 8 – 10 hours on varying terrain then pumped water for a further 4 hours. Measurements taken included height, body mass, waist circumference and skin-fold thickness at four regions of the body, and were taken before, during and at the end of the expedition. The approximate daily calorific intake for each team member was 2400 – 3000 kcal.

Results

Significant decreases in mean body mass (p<0.001, d=0.50) and mean BMI (p<0.001, d=0.67) were observed after the 20 day trek compared to baseline values. Mean waist circumference decreased during the expedition (p<0.001, d=0.67). There were significant reductions in all measures of skinfold thicknesses and overall percentage body fat at Day 13 (p<0.001, d=1.19) and Day 21 (p<0.001, d=1.98) in comparison to baseline values.

Conclusions

All participants lost significant amounts of both body mass and body fat, with body fat reducing by over 30%.
A Survey of Experience of Parenteral Analgesia at Role 1
Authors: Davey Colette , Mieville KE , Simpson R , Aldington D
Published: March 2013

Objectives:

To assess the confidence of deploying Role 1 Medical Officers (MOs)in the use of parenteral analgesia, to collate opinion as to whether analgesia training for Role 1 MOs is fit for purpose and to explore options for future analgesic approaches at Role 1.

Methods:

A survey distributed to Role 1 doctors prior to deployment to Afghanistan.

Results:

Areas of expressed concern included the use of ketamine and a lack of experience of intraosseous drug administration. Qualitative data collected included anecdotal experiences with analgesia administration which provides evidence to support a change in training.

Conclusions:

Doctors have the capability to provide good analgesic care but lack the confidence and experience to do it effectively. Improved analgesia training is required for deploying Role 1 MOs.
A Proposed Model for Improving Battlefield Analgesia Training: Post-Graduate Medical Officer Pain Management Day
Authors: Davey Colette , Mieville KE , Simpson R , Aldington D
Published: March 2013

In response to increasing awareness of the need to improve Post Graduate Medical Officers training in the use of analgesics when on Operations and exercises, a new “Pain Day” format has been realised and included in the Post Graduate Medical Officers Course. This article discusses the format of the Pain Day; gives evidence of the feedback received; explores areas where further training may be required and suggests mechanisms through which improved training could be provided throughout the armed forces medical community.