To refer or not to refer: a qualitative study of reasons for referral from Role 1.

OBJECTIVES: There are currently over 9000 British soldiers serving in Afghanistan. The Defence Medical Services provide primary health care to soldiers at forward locations using Regimental Medical Officers (RMOs) and General Duties Medical Officers (GDMOs). If required, GDMOs can refer patients to senior colleagues. Currently, little is known about the reasons for referrals by GDMOs. This study aims to identify the main factors affecting why GDMOs refer from forward locations. METHODS: Nine GDMOs, who deployed on Operation HERRICK 13, were invited to join the study. They maintained a log of their referrals for two 14 day periods, one in each half of their tour. In addition, a semi-structured interview was performed with each GDMO in order to elicit the common themes surrounding referrals. RESULTS: The mean referral rate was 0.9 referrals/GDMO/week. The main reasons for referral were dental problems, musculoskeletal injuries, abdominal pain of unknown cause, and ano-genital problems. Factors that influenced referrals included availability of forwardly projected services (dentist and physiotherapist), manpower availability at the locations, the availability of flights (affected by weather, enemy action, and schedule of routine flights), and the timing of the tour in relation to leave. CONCLUSIONS: Referrals from GDMOs were due to doctor inexperience in the treatment of a particular condition, lack of access to investigations and the potential for deterioration in a location without adequate support. The referral decision process was affected by the patient's importance with regards to the mission, the weather and access to safe transportation. The introduction of clinical guidelines for common conditions in conjunction with minor alterations to GDMO training could help reduce referrals from Role 1, preserving manpower, reducing costs, and minimising risk to evacuation aircraft.

Dermatology on Operation HERRICK.

OBJECTIVES: To identify the dermatological conditions affecting British troops in Afghanistan, understand how they are treated and identify potential areas for improvement. METHODS: Data was collected from the Defence Analytical Services and Advice agency and the Operational Emergency Department Attendance Register via the Disease and Non Battle Injury working group. Additional data was collected from J4 - Medical Permanent Joint Headquarters. Treatment information from Clinical Guidelines on Operations (CGOs), Medics' protocols, and primary care module composition was reviewed. RESULTS: Dermatological conditions accounted for 1 in 5 attendances to a Role 1 Medical Treatment Facility during the study period. They were consistently in the top five reasons for working days lost, and had a comparatively high hospital admission rate (0.3/1000 Population at Risk (PAR)/month) and a repatriation rate similar to other medical specialties such as respiratory and neurology (0.1/1000 PAR/month). Treatment appeared to be adequate based on declining return attendance numbers, although CGOs were found to lack dermatological protocols and medic protocols were eight years old and not specific to the current operational requirements. CONCLUSIONS: Although treatments are working for dermatological conditions, areas for optimisation of health care have been identified, such as updating medic protocols to include campaign specific information and latest guidelines in the CGOs. Pre-deployment dermatologist-devised treatment plans and tele-consults may also help keep soldiers with pre-existing skin complaints in theatre.