bluuebunny/crossref_metadata_2025_split huggingface dataset:
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

AimsThe 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.ResultsAnalysis 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.ConclusionRegular 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.
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.
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

ObjectivesTo critically evaluate the predisposing factors and symptomatology that resulted in serving officers and soldiers requiring a Mental Health (MH) assessment.Methods317 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.ResultsThree 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.ConclusionThe 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.
British Military Experience of Pre-Hospital Paediatric Trauma in Afghanistan
Authors: Walker N , Russell RJ , Hodgetts TJ 
Published: March 2013

IntroductionTrauma 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.MethodsA retrospective analysis of all paediatric patients transported by the helicopter-borne MERT between 01 May 2006 and 31 December 2007 in Helmand Province, Afghanistan.Results78 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.ConclusionA 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

ObjectivesTo 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.MethodsThis 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.ResultsMERTs 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.ConclusionsThe 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.
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.
A Survey of Primary Health Care Provision at a Forward Operating Base in Afghanistan During Operation HERRICK 10
Authors: Hawksley O J , Jeyanathan J , Mears K , Simpson R 
Published: March 2013

ObjectivesTo record and discuss patient morbidity treated in a Forward Operating Base in Afghanistan and explore who delivers the care.MethodsProspective case series of all patients presenting to the Regimental Aid Post during a summer tour of Afghanistan.Results1903 episodes of care were delivered over a 6-month period in 2009. Afghan patients represented 32.8% of all cases seen. The majority of cases were related to primary care. The most common types of presentations were dermatological, other general medical conditions, other injuries and disorders of the digestive tract. Combat Medical Technicians (CMT) were able to deal with 47% of all cases using the CMT protocols.ConclusionsPrimary care in forward areas involves patients from a spectrum of backgrounds with multiple morbidities and diagnoses. Consideration should be given for further research into the area of the consultation at the front line to aid patient care. Combat Medical Technicians were able to treat nearly 50% of all cases by themselves but this left a significant number where the assistance of a Medical Officer was required. Consideration should be given for further research into preparation of Combat Medical Technicians for autonomous working at the front line.
Changing Patterns In Tobacco Consumption Among Spanish Military Personnel Under Stressful Conditions
Authors: Granda-Orive José Ignacio de , López-Aguilar JC , García-Río F , Solano-Reina S , Jiménez-Ruiz CA , Roig-Vázquez F 
Published: March 2013

ObjectiveA study is made to determine the prevalence of smoking and its variation over time in a group of Spanish military personnel (MP) under stressful conditions.MethodsA questionnaire specifically designed for this study was administered to the entire MP contingent assigned to Banghis province (Afghanistan) between July and October 2009. A descriptive analysis was made (p < 0.05, 95%CI).ResultsThe study sample comprised 254 MP (males 239; mean age 32 years (SD 9)). A total of 39.8% (95%CI; 33.7 – 45.8) were smokers, while 3.1% (95%CI; 1.0 – 5.3%) were former smokers. Regarding smoking habit before and at the end of deployment, one-half (50.5%) of the smokers declared that they smoked the same as before, 20.8% more than before, and 18.8% less than before. In turn, 5.9% of the smokers claimed to have started to smoke in the course of deployment, while 4% of the former smokers declared that they had quit smoking. The MP who quit smoking were younger than those who began to smoke (24 ± 5 vs 39 ± 9 years, p = 0.038). Moreover, the heavy smokers (≥ 15 cigarettes/day) reduced tobacco consumption, while the less heavy smokers increased the habit (p < 0.0001).ConclusionsThe prevalence of daily smokers is high among MP. The majority of smokers smoke the same at the end of deployment. Those who quit smoking during the mission are significantly younger than those who begin to smoke. In turn, heavy smokers reduced their habit, while less heavy smokers increased smoking.
An Observational Study into the Levels of Evidence Presented at the Combined Services Orthopaedic Society Annual Meeting
Authors: Bonner Tim , Mountain A , Eardley WGP , Clasper JC 
Published: March 2013

ObjectivesThe role of Evidence Based Medicine in clinical care is to provide a framework for the integration of expertise, current evidence and the needs of the individual patient. Research presented at scientific meetings is an important source of such evidence, informing clinical decision making both on military operations and in home nation health care systems. The aim of this study is to review the levels of evidence presented at the Combined Services Orthopaedic Society (CSOS) and two other related scientific meetings.MethodsRetrospective review of abstracts presented at the annual scientific meetings of the CSOS, Society of Military Orthopaedic Surgeons (SOMOS) and the British Trauma Society (BTS). Basic science studies, animal studies, cadaveric studies, surveys and guest lectures were excluded. Research abstracts were categorised according to the Centre for Evidence- Based Medicine’s (CEBM) hierarchy of evidence. Statistical comparison was performed to investigate differences in evidence levels presented at each scientific meeting and between each year of the CSOS meeting.Results596 abstracts met the inclusion criteria for this study (179 CSOS, 173 SOMOS, 244 BTS). Level IV evidence accounted for the majority of presented abstracts at each meeting (72.6% CSOS, 69.4% SOMOS, 68.9% BTS). Level I evidence was uncommon at each meeting (6.1% CSOS, 5.2% SOMOS, 2.9% BTS). There was no statistical difference in the evidence levels presented at the three scientific meetings.ConclusionsThe proportion of comparative clinical studies (Levels I-III) presented at military or trauma societies’ scientific meetings reflects the difficulty of performing research in emergency surgery. This is further exacerbated in the military environment where operational commitments and delivery of care take priority. However, the future value of comparative clinical research in battlefield healthcare could have an enduring legacy that shapes trauma care for many decades.
The Clinical Outcome of UK Military Personnel Who Received a Massive Transfusion in Afghanistan During 2009
Authors: Allcock Edward , Woolley T , Doughty H , Midwinter M , Mahoney PF , Mackenzie I 
Published: March 2013

ObjectivesThe UK Defence Medical Services has developed a Massive Transfusion Protocol (MTP) that forms part of the initial Damage Control Resuscitation process for severely injured combat casualties. The key objectives of this retrospective review of MTP recipients are to document the survival rates, level of critical care support required and the blood components transfused as part of the Massive Transfusion Protocol in Afghanistan during 2009. In addition to providing a measure of our current effectiveness it should also provide a reference point for future reviews as the MTP continues to evolve.MethodsThis was a collaborative project involving the Royal Centre for Defence Medicine and the Critical Care Department, University Hospitals Birmingham. It was limited to UK military personnel who were injured in 2009 and received massive transfusions (defined as the transfusion of 10 or more units of packed red blood cells over a 24-hour period) at Camp Bastion Role 3 Medical Facility, Afghanistan.ResultsDuring the 12-month period, 59 personnel received massive transfusions. 51 (86%) personnel survived to be discharged from hospital in the UK. 48 (92%) personnel required ventilatory support for a median of 3 (2-8) days. The longest period of ventilation was 40 days; 29 (55%) personnel required vasopressor support and eight personnel (15%) required renal replacement therapy. The median total transfusion of blood components was 45 (28.5-62) units. There were seven transfusions of more than 100 units. Five of the personnel in this group (including the recipient of a 237-unit transfusion) survived to be discharged from University Hospitals Birmingham. On average, 1.21 (SD 0.28) units of packed red blood cells were transfused for every unit of fresh frozen plasma.ConclusionsThe use of the current MTP was associated with a high rate of survival. Survivors require a continuity of critical care with a median demand for 3 days. The early use of plasma and platelets can be successfully delivered in the battlefield despite operational and logistic constraints.
General Practice - Reflection on Five Years of Multidisciplinary Training at Medical Centre Gütersloh
Authors: van den Heuvel HGJ 
Published: March 2013

BackgroundMedical Centre Gütersloh is a primary care setting which provides the full range of general practice care for British Forces Germany Health Service (BFG HS). The aim of this article is to evaluate the multidisciplinary training organised by the author there, to exchange information and to provide suggestions for improvement and development.MethodsDescription of the training scheme and analysis of routinely collected management data.ResultsThe training scheme is based on adult education principles with a focus on interactive learning. Over the period November 2005 – July 2010 a total of 1201 members of staff from various disciplines participated in 86 documented training sessions. The majority of the attending staff considered the training to be relevant, interesting and well presented. A substantial proportion indicated that they would change their practice as a result of the training. These views remained stable over time. The majority of facilitators consisted of medical centre employees.ConclusionsThis article provides an overview on five years of multidisciplinary training in a general practice setting. Overall feedback from staff suggests that the training has been highly valued over those years. However, it is recognised that this evaluation has its limitations and suggestions are made regarding how these types of training schemes can be improved and developed further.
A Comparison of Performance Between Teflon® and Polyurethane Safety Cannulae at Extremes of Operating Temperatures
Authors: Jeyanathan J , Webster BB , Hawksley OJ , Mellor A J 
Published: March 2013

ObjectivesIn the United Kingdom, approximately eight million peripheral cannulations are performed each year. Intravenous cannulae are made from either polytetrafluoroethylene (Teflon®) or polyurethane. Polyurethane has a lower incidence of thrombophlebitis, however the physical characteristics of polyurethane may make the cannulae difficult to use at higher ambient temperatures. This effect maybe of importance to those involved in cannulation in extreme environments and especially for military doctors deployed in current theatres of operations.MethodsIn a randomised single blinded study we investigated the different characteristics of Teflon® and polyurethane cannulae (Vasofix® Safety Cannulae, B Braun) at three different temperatures (-10ºC, 21ºC and 40 ºC).ResultsThere is no statistically significant difference in the ease or speed of cannulation of either polyurethane or Teflon® safety cannulae in extremes of temperature.ConclusionsThis study provides evidence that performance of polyurethane safety cannulae are not impaired by temperature extremes.