Extending existing recommended military casualty evacuation timelines will likely increase morbidity and mortality: a UK consensus statement.

INTRODUCTION: Future conflicts may have limited use of aviation-based prehospital emergency care for evacuation. This will increase the likelihood of extended evacuation timelines and an extended hold at a forward hospital care facility following the completion of damage control surgery or acute medical interventions. METHODS: A three-round Delphi Study was undertaken using a panel comprising 44 experts from the UK armed forces including clinicians, logisticians, medical planners and commanders. The panel was asked to consider the effect of an extended hold at Deployed Hospital Care (Forward) from the current 2-hour timeline to +4, +8, +12 and +24 hours on a broad range of clinical and logistical issues. Where 75% of respondents had the same opinion, consensus was accepted. Areas where consensus could not be achieved were used to identify future research priorities. RESULTS: Consensus was reached that increasing timelines would increase the personnel, logistics and equipment support required to provide clinical care. There is a tipping point with a prolonged hold over 8 hours, after which the greatest number of clinical concerns emerge. Additional specialties of surgeons other than general and orthopaedic surgeons will likely be required with holds over 24 hours, and robust telemedicine would not negate this requirement. CONCLUSIONS: Retaining acute medical emergencies at 4 hours, and head injuries was considered a particular risk. This could potentially be mitigated by an increased forward capacity of some elements of medical care and availability of a CT scanner and intracranial pressure monitoring at over 12 hours. Any efforts to mitigate the effects of prolonged timelines will come at the expense of an increased logistical burden and a reduction in mobility. Ultimately the true effect of prolonged timelines can only be answered by close audit and analysis of clinical outcomes during future operations with an extended hold.

A pilot study to evaluate the utility of live training (LIVEX) in the operational preparedness of UK military trauma teams.

BACKGROUND: With the end of UK military operations in Iraq and Afghanistan, it is essential that peacetime training of Defence Medical Services (DMS) trauma teams ensures appropriate future preparedness. A new model of pre-deployment training involves placement of formed military trauma teams into civilian trauma centres. This study evaluates the benefit of 'live training during an exercise period' (LIVEX) for DMS trauma teams. METHODS: A cross-sectional questionnaire-based survey of participants was conducted. Quantitative data were collected prior to the start and on the final day. Written reports were collected from the coordinators. Thematic analysis was used to identify emergent themes in a supplementary, qualitative analysis. RESULTS: Each team comprised 13 personnel and results should be interpreted with knowledge of this small sample size. The response rate for both the pre-LIVEX and post-LIVEX questionnaire was 100%. By the end of the week, 89% of participants (n=23) stated LIVEX was an 'appropriate or very appropriate' way of preparing for an operational role compared with 40% (n=9) before the exercise (p<0.01). However, completing LIVEX made no difference to participants' personal perception of their own operational preparedness. Thematic analysis suggested greater training benefit for more junior members of the team; from Regulars and Reservists training together; and from two-way exchange of information between DMS and National Health Service medical staffs. CONCLUSIONS: Completing LIVEX made no statistically significant difference to participants' personal perception of their own operational preparedness, but the perception of LIVEX as an appropriate training platform improved significantly after conducting the training exercise.

Putting Role 1 first: the Role 1 capability review.

AIM: To quantify the risk for delivering care at Role 1 in the Land Environment (point of wounding to hospital care) on current operations and set the conditions for systematic change to enhance future capability. POPULATION: UK, US and Danish Army Role 1 Subject Matter Experts (SMEs) METHODS: (1) Questionnaire study ofUK SMEs to determine capability gaps; (2) Questionnaire study of US and Danish SMEs to benchmark UK capability; (3) Semi-structured interviews of UK SMEs; (4) In-theatre evaluation of deployed Role 1. RESULTS: Thirty two SMEs completed the questionnaire (68% response rate), comprising 25 medical officers (20 in clinical appointments; five in command and staff appointments), six nurses and one medical support officer. Results of the entire review were collated as a cross-Defence Lines of Development analysis, separating the specific experience of 1 Medical Regiment's Hybrid Foundation Training (HFT), Mission Specific Training (MST) and deployment cycle from the analysis gained from questionnaire studies, SME consultation and documentary evidence. RECOMMENDATIONS AND CONCLUSIONS: The review generated 77 recommendations and 38 sub-recommendations. The top six messages of the review were (1) To balance the expressed desire to increase the ratio of trained Team Medics with the reality of generating credible instructors with clinical experience; (2) To recognise that inadequate experience for Combat Medical Technicians in Primary Healthcare in the Firm Base undermines their operational preparedness; (3) To recognise that Current Regimental Aid Post (RAP) at contingency without power lacks the rudimentary infrastructure of a modern Medical Treatment Facility; (4) To recognise that inappropriate deployment of personnel with chronic disease or acutely limiting conditions is a consistent trend for 20 years that highlights continuing system weaknesses in applying protective medical grading; (5) To accept that General Practitioner manning requires re-evaluating as an Operational Pinch Point, reviewing all options to maintain operational effectiveness including, but not focusing on, incentives; and (6) To recognise that a best practice template for Role 1 Healthcare Governance has been created that must endure.

Civilian firearm injury and death in England and Wales.

INTRODUCTION: There is currently concern in the UK that injuries and deaths caused by firearms are increasing. This is supported by small local studies but not by wider research to inform targeted prevention programmes. METHODS: A retrospective analysis was performed of firearm injuries from the Trauma Audit and Research Network (TARN) database (1998-2007), the largest national registry of serious injuries. Data were analysed to determine temporal trends in the prevalence of firearm injuries and demographic characteristics of firearm victims. The UK Office of National Statistics provided data on all deaths by firearms as TARN does not record prehospital deaths. RESULTS: Of 91 232 cases in the TARN database, 487 (0.53%) were due to firearm injury. There were 435 men and 52 women of median age 30 years. The median New Injury Severity Score in men was 18 with a mortality of 7.4%, compared with 15.5 and 3.8% for women. The highest rate of firearm injuries as a proportion of all injuries was submitted from London (1.4%), with the South East (0.23%) submitting the lowest rate. 90.5% resided in urban areas, 78% presented outside 'normal' hours and 90% were alleged assaults. As a proportion of all injuries submitted, a small upward trend in the prevalence of deaths due to firearms was demonstrated over the study period. An increase in homicides since 2000 was also noted with an increasingly younger population being involved. In contrast, data from the Office of National Statistics showed that the greatest number of deaths were self-inflicted rather than homicides (984 vs 527), with Wales having the highest number of such deaths and predominantly involving older men. CONCLUSIONS: Deaths and serious injuries caused by firearms remain rare in the civilian population of England and Wales, although an upward trend can be described. Victims of assault and homicide are predominantly young men living in urban areas and the population involved is getting younger. However, of all deaths, self-inflicted wounds are nearly twice as common as assaults, affecting predominantly older men living in more rural areas.

The deployed medical director: managing the challenges of a complex trauma system.

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

Management of intestinal injury in deployed UK hospitals.

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.

The role of trauma scoring in developing trauma clinical governance in the Defence Medical Services.

This paper discusses mathematical models of expressing severity of injury and probability of survival following trauma and their use in establishing clinical governance of a trauma system. There are five sections: (i) Historical overview of scoring systems--anatomical, physiological and combined systems and the advantages and disadvantages of each. (ii) Definitions used in official statistics--definitions of 'killed in action' and other categories and the importance of casualty reporting rates and comparison across conflicts and nationalities. (iii) Current scoring systems and clinical governance--clinical governance of the trauma system in the Defence Medical Services (DMS) by using trauma scoring models to analyse injury and clinical patterns. (iv) Unexpected outcomes--unexpected outcomes focus clinical governance tools. Unexpected survivors signify good practice to be promulgated. Unexpected deaths pick up areas of weakness to be addressed. Seventy-five clinically validated unexpected survivors were identified over 2 years during contemporary combat operations. (v) Future developments--can the trauma scoring methods be improved? Trauma scoring systems use linear approaches and have significant weaknesses. Trauma and its treatment is a complex system. Nonlinear methods need to be investigated to determine whether these will produce a better approach to the analysis of the survival from major trauma.

British military experience of pre-hospital paediatric trauma in Afghanistan.

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.

The Joint Theatre Clinical Case Conference (JTCCC): clinical governance in action.

OBJECTIVES: To quantify the type and nature of the lessons and issues arising from the Joint Theatre Clinical Case Conference METHODS: An evaluation of all JTCCC minutes from inception on 30 Mar 07 to 05 Jun 08 (n = 61) was performed in Jul 08. Each separate issue (n = 207) was assigned a NATO 'J' category and further sub-divided into clinical and non-clinical issues. Detail of whether the issues were raised for information only, or required action to be taken was recorded, as was the outcome of this action. RESULTS: A wide range of clinical and non-clinical issues (J1-J8), were identified. 23% (47) of the 207 issues were raised for information only. 77% (160) issues required action to be taken. 109 were dosed within 3 weeks. 23 took more than 3 weeks to close. Eight weeks after the study period 28 issues were still being actively resolved. 85% of JTCCC teleconferences had full participation from both theatres. Technical difficulties and/or the treatment of casualties prevented the participation of one or both theatres on 9 occasions. CONCLUSIONS: JTCCC supports deployed clinicians and enables rapid resolution of issues affecting combat casualty care. It is limited by its focus on UK casualties only. Although intended as a Clinical Governance tool the evidence of this review is that JTCCC has wider effects in a number of clinical and non-clinical areas.

Operational morbidity analysis: ophthalmic presentations during Operation TELIC.

AIM: This paper analyses all ophthalmic attendances to a deployed emergency department (ED) in Iraq to identify patterns of injury to optimise patient care, plan equipment tables for future operations and emphasise need for prevention of ocular morbidity. METHODS: The Academic Department of Military Emergency Medicine at the Royal Centre for Defence Medicine in Birmingham maintains an electronic database with derails on all attendances to the emergency departments deployed on Operations. This Operational Emergency Department Attendance Register (OpEDAR) was searched for all patients with medical classification of Ophthalmology over a 52 month period between 1 March 2003 and 30 June 2007. RESULTS: During this period 30,195 patients were seen in the ED on Operation Telic and are available for analysis. Patients with ophthalmic complaints account for 5.3% of all presentations to the ED and rank as the 7th most common reason for attendance. CONCLUSION: This paper identifies patterns of injury to enable future planning of equipment tables and identifies the need for prevention of injury wherever possible. Implications on days lost from full active duty for the injured can be extrapolated. More data needs to be collated on the use of eye protection and the relevance of contact lenses in deployed personnel with eye injuries.

Military pre-hospital care: why is it different?

There are significant differences between the civilian and military pre-hospital trauma systems relating to patient load, injury severity and the nature of the environment. This is reflected in differing clinical paradigm and treatment protocols. There is opportunity, however, for the two systems to learn from each other, which is particularly relevant at the time the UK is actively engaging with defining the requirement for trauma centres and the re-configuration of civilian trauma systems.

What is the ideal pre-hospital analgesic?--a questionnaire study.

AIM: To determine clinical opinion of effectiveness of current battlefield analgesia and the realistic options to improve future analgesia in hostile environments. METHODS: Structured electronic questionnaire distributed to selected individuals in UK and on operations. POPULATION: 122 UK Defence Medical Services and US Medical Corps doctors, nurses and combat medical technicians involved in the early management of severe trauma on deployment. RESULTS: 54 (44%) agreed and 63 (52%) disagreed that intramuscular morphine had the ideal analgesic properties for the military pre-hospital environment. Over half of those with operational experience reported multiple instances of intramuscular morphine providing inadequate analgesia. 86 (70%) desired a more potent analgesic than morphine in the first hour following injury. 101 (83%) identified simplicity and reliability of use by a soldier as of high importance. 99 (81%) identified rapid onset of action of high importance. With regard to an acceptable route of drug self-administration, 88 (72%) supported a nasal spray; 78 (64%) supported a sustained release buccal tablet (adhesive to the gum); 61 (50%) supported a disposable inhaler of volatile gas (although 91% had no experience of the currently available drug in this formulation); and 55 (45%) supported a skin patch. CONCLUSION: Intramuscular morphine does not meet the needs of the majority of clinical stakeholders. Alternative routes of self-administration are acceptable, but support for available commercial solutions is clouded by incomplete awareness. Anaesthetists and emergency physicians desire a multimodal approach to battlefield analgesia within the evacuation chain.

Symptoms of post-concussional syndrome are non-specifically related to mild traumatic brain injury in UK Armed Forces personnel on return from deployment in Iraq: an analysis of self-reported data.

BACKGROUND: Mild traumatic brain injury (mTBI) is being claimed as the 'signature' injury of the Iraq war, and is believed to be the cause of long-term symptomatic ill health (post-concussional syndrome; PCS) in an unknown proportion of military personnel. METHOD: We analysed cross-sectional data from a large, randomly selected cohort of UK military personnel deployed to Iraq (n=5869). Two markers of PCS were generated: 'PCS symptoms' (indicating the presence of mTBI-related symptoms: none, 1-2, 3+) and 'PCS symptom severity' (indicating the presence of mTBI-related symptoms at either a moderate or severe level of severity: none, 1-2, 3+). RESULTS: PCS symptoms and PCS symptom severity were associated with self-reported exposure to blast whilst in a combat zone. However, the same symptoms were also associated with other in-theatre exposures such as potential exposure to depleted uranium and aiding the wounded. Strong associations were apparent between having PCS symptoms and other health outcomes, in particular being a post-traumatic stress disorder or General Health Questionnaire case. CONCLUSIONS: PCS symptoms are common and some are related to exposures such as blast injury. However, this association is not specific, and the same symptom complex is also related to numerous other risk factors and exposures. Post-deployment screening for PCS and/or mTBI in the absence of contemporaneous recording of exposure is likely to be fraught with hazards.

A realistic model for catastrophic external haemorrhage training.

External haemorrhage is a significant cause of combat morbidity and mortality. UK DMS have introduced topical haemostatic agents (HemCon, QuikClot) for use as an adjunct to control catastrophic external haemorrhage. Realistic training in new equipment is essential. A model is described that is simple, reproducible, valid, realistic and currently unique in its opportunity to train soldiers to deal with life-threatening external bleeding, without recourse to live animal training. The model has been used successfully to train UK DMS medics, nurses and doctors in Afghanistan.

Tourniquet use in the civilian prehospital setting.

Tourniquets are an effective means of arresting life-threatening external haemorrhage from limb injury. Their use has not previously been accepted practice for pre-hospital civilian trauma care because of significant concerns regarding the potential complications. However, in a few rare situations tourniquet application will be necessary and life-saving. This review explores the potential problems and mistrust of tourniquet use; explains the reasons why civilian pre-hospital tourniquet use may be necessary; defines the clear indications for tourniquet use in external haemorrhage control; and provides practical information on tourniquet application and removal. Practitioners need to familiarise themselves with commercial pre-hospital tourniquets and be prepared to use one without irrational fear of complications in the appropriate cases.

Damage control resuscitation.

Damage Control Resuscitation (DCR) is a novel concept that draws together a series of technical and organisational advances in combat casualty care. It is consistent with and encapsulates the established concept of damage control surgery (DCS).