War and disaster are forcing a major rethink around mass casualty management.

Mass casualty events (MASCAL) do not follow the same rules as typical major incidents. In the West at least, the latter often occur in stable, networked trauma systems, whereas MASCAL are characterised by overwhelming numbers of patients, compounded by protracted scene and transport times, decompensated response systems and significant disruption to infrastructure, command and control.This paper describes the 8Ds approach being taken by the UK Defence Medical Services and the North Atlantic Treaty Organization Emergency Medicine Panel framework to approach MASCAL. The eight domains were derived from literature about management of casualties in the World Wars, and also from approaches taken by civilian health systems as they struggle to manage increasing demand. They are: distribute; decompress; delay; delegate; deliver faster and deliver better; dynamic levels of care; and de-escalate These domains will allow a structured approach to research and innovate around MASCAL, informing better guidelines for their management.

Clinical activity at the UK military level 2 hospital in Bentiu, South Sudan during Op TRENTON from June to September 2017.

INTRODUCTION: Diseases and non-battle injuries (DNBIs) are common on UK military deployments, but the collection and analysis of clinically useful data on these remain a challenge. Standard medical returns do not provide adequate clinical information, and clinician-led approaches have been laudable, but not integrated nor standardised nor used long-term. Op TRENTON is a novel UK military humanitarian operation in support of the United Nations Mission in South Sudan, which included the deployment of UK military level 1 and level 2 medical treatment facilities at Bentiu to provide healthcare for UK and United Nations (UN) personnel. METHODS: A service evaluation of patient consultations and admissions at the UK military level 2 hospital was performed using two data sets collected by the emergency department (ED) and medicine (MED) teams. RESULTS: Over a three-month (13-week) period, 286 cases were seen, of which 51% were UK troops, 29% were UN civilians and 20% were UN troops. The ED team saw 175 cases (61%) and provided definitive care for 113 (40%), whereas the MED team saw and provided definitive care for 128 cases (45%). Overall, there were 75% with diseases and 25% with non-battle injuries. The most common diagnoses seen by the ED team were musculoskeletal injuries (17%), unidentified non-malarial undifferentiated febrile illness (UNMUFI) (17%), malaria (13%), chemical pneumonitis (13%) and wounds (8%). The most common diagnoses seen by the MED team were acute gastroenteritis (AGE) (56%), UNMUFI (12%) and malaria (9%). AGE was due to viruses (31%), diarrhoeagenic Escherichia coli (32%), other bacteria (6%) and protozoa (12%). CONCLUSION: Data collection on DNBIs during the initial phase of this deployment was clinically useful and integrated between different departments. However, a standardised, long-term solution that is embedded into deployed healthcare is required. The clinical activity recorded here should be used for planning, training, service development and targeted research.

UK Defence Medical Services' support to the development of a multiagency major incident plan in South Sudan.

UK Defence Medical Services personnel deployed in support of the United Nations Mission in South Sudan as part of Operation TRENTON in 2017-2018. One key contribution was the development of a multiagency major incident plan in collaboration with key stakeholders within the region, including our UN partners, other troop-contributing countries and non-governmental organisations. This paper describes the process and contribution made, with some transferable lessons for future similar operations, such as adaptation of our courses. Major incident management is one of several technical areas ripe for a proactive Defence Healthcare Engagement strategy, seeking to offer capacity building in areas where Defence is rich in expertise that is highly sought after by other sectors.

Medical Civil-Military Relationships: A Feasibility Study of a United Kingdom Deployment in South Sudan.

OBJECTIVES: Civil-military relationships are necessary in humanitarian emergencies but, if poorly managed, may be detrimental to the efforts of humanitarian organizations. Awareness of guidelines and understanding of risks relating to the relationship among deployed military personnel have not been evaluated. METHODS: Fifty-five military and 12 humanitarian healthcare workers in South Sudan completed questionnaires covering experience, training and role, agreement with statements about the deployment, and free text comments. RESULTS: Both cohorts were equally aware of current guidance. Eight themes defined the relationship. There was disagreement about the benefit to the South Sudanese people of the military deployment, and whether military service was compatible with beneficial health impacts. Two key obstacles to the relationship and 3 areas the relationship could be developed were identified. CONCLUSION: This study shows that United Kingdom military personnel are effectively trained and understand the constraints on the civil-military relationship. Seven themes in common between the groups describe the relationship. Current guidance could be adapted to allow a different relationship for healthcare workers.

Challenges of managing snakebite envenomation in a deployed setting.

Snake bite envenomation causes a significant health burden globally, especially in austere or resource poor settings. This case series describes envenomation in two adults and two children presenting to the Role 3 Medical Treatment Facility in Camp Bastion, Afghanistan. Each case has similarities with respect to the coagulopathy of envenomation but differs in terms of time delay to presentation and response to treatment, including reactions to antivenom. We discuss the challenges and ethical dilemmas in delayed-presentation snakebite, the diagnosis and treatment of coagulopathy and the role of antivenom and surgical debridement.

Paediatric casualties during OP TELIC.

AIM: To audit all paediatric attendances to a British Army Field Hospital during warfighting. POPULATION: All patients <16-years-old who presented to 34 Field Hospital Accident & Emergency (A&E) Department during warfighting phase of OPTELIC (27 Mar 03 to 01 May 03). METHOD: A retrospective analysis of A&E attendance register, A&E clinical records, and A&E trainees' logbooks from the department of 34 Field Hospital. RESULTS: Seventy eight children were treated, mean age 7.9 years. 65.4% were male and 34.6% female. Children accounted for 2.9% of all patients (total attendances 2720) and 32.9% of non-coalition patients (non-coalition attendances 237). 44 (56%) children had burns as the principal injury; 7 (9%) had shrapnel injuries, 5 (6%) had blunt trauma from a road traffic accident. Only one child had GSW. 17% of attendances were related to 'medical' complaints rather than trauma. 78% of children required transfer to a specialist facility. CONCLUSIONS: Recognition of the potential for paediatric casualties is required to facilitate appropriate planning, training and equipping of medical units deployed on future operations.