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.

Military and Civilian Trauma System Integration: A Global Case Series.

INTRODUCTION: Traumatic injury is a leading cause of morbidity globally, particularly in low-income and middle-income countries (LMICs). In high-income countries (HICs), it is well documented that military and civilian integration can positively impact trauma care in both healthcare systems, but it is unknown if this synergy could benefit LMICs. This case series examines the variety of integration between the civilian and military systems of various countries and international partnerships to elucidate if there are commonalities in facilitators and barriers. METHODS: A convenience sampling method was utilized to identify subject matter experts on civilian and military trauma system integration. Data were collected and coded through an iterative process, focusing on the historical impetuses and subsequent outcomes of civilian and military trauma care collaboration. RESULTS: Eight total case studies were completed, five addressing specific countries and three addressing international partnerships. Themes which emerged as drivers for integration included history of conflict, geography, and skill maintenance for military physicians. High-level government support was a central theme for successful integration, and financial issues were often seen as the greatest barrier. CONCLUSIONS: Various approaches in civilian-military integration exist throughout the world, and the studied nations and international partnerships demonstrated similar motivators and barriers to integration. This study highlights the need for further investigation, particularly in LMICs, where less is known about integration strategies.

Prospective Surveillance of Respiratory Infections in British Antarctic Survey Bases During the COVID-19 Pandemic.

BACKGROUND: The British Antarctic bases offer a semiclosed environment for assessing the transmission and persistence of seasonal respiratory viruses. METHODS: Weekly swabbing was performed for respiratory pathogen surveillance (including SARS-CoV-2), at 2 British Antarctic Survey bases, during 2020: King Edward Point (KEP, 30 June to 29 September, 9 participants, 124 swabs) and Rothera (9 May to 6 June, 27 participants, 127 swabs). Symptom questionnaires were collected for any newly symptomatic cases that presented during this weekly swabbing period. RESULTS: At KEP, swabs tested positive for non-SARS-CoV-2 seasonal coronavirus (2), adenovirus (1), parainfluenza 3 (1), and respiratory syncytial virus B (1). At Rothera, swabs tested positive for non-SARS-CoV-2 seasonal coronavirus (3), adenovirus (2), parainfluenza 4 (1), and human metapneumovirus (1). All bacterial agents identified were considered to be colonizers and not pathogenic. CONCLUSIONS: At KEP, the timeline indicated that the parainfluenza 3 and adenovirus infections could have been linked to some of the symptomatic cases that presented. For the other viruses, the only other possible sources were the visiting ship crew members. At Rothera, the single symptomatic case presented too early for this to be linked to the subsequent viral detections, and the only other possible source could have been a single nonparticipating staff member.

Time trends in adrenaline auto-injector dispensing patterns using Australian Pharmaceutical Benefits Scheme data.

AIM: Adrenaline auto-injector (AAI) dispensing data, a community-based proxy for number of individuals at risk of anaphylaxis, provides complementary information on time trends of anaphylaxis risk in addition to hospital admission data. We examined trends of AAI dispensing over a 10-year period (from January 2005 to December 2014) in Australia. METHODS: Individuals with dispensed AAI were identified from a 10% random sample of Australian Pharmaceutical Benefits Scheme (PBS) data. PBS is the Australian national drug subsidy programme covering all Australians. Cumulative incidence and incidence rates of individuals with AAI were calculated. We assessed difference by age, sex, state and time trends. RESULTS: The cumulative incidence of individuals with AAI in 2005-2014 was 75.43/100 000 (95%CI 75.07-75.80/100 000). Incidence rate of individuals with AAI increased from 2005 to 2014 (from 71.47 to 82.07 per 100 000 person-years) although this varied by state. Over the time assessed, there was a shift to more prescriptions being provided by general practitioners (GP) rather than specialists. Children (0-19 years) were more likely to have been prescribed an AAI from a specialist and adults from a GP. CONCLUSION: Overall, an increase in dispensed AAI mirrored other evidence for a rising prevalence of allergy. This increase could also reflect changes in prescribing practices or increased awareness and education of health-care professionals on anaphylaxis and indications for prescribing AAI. The rising rate of AAI prescribed by GPs compared to decreasing rates by specialists suggests a changing response of the Australian health-care system to the increased burden of anaphylaxis.

Understanding medical civil-military relationships within the humanitarian-development-peace 'triple nexus': a typology to enable effective discourse.

The interface between humanitarianism, development and peacebuilding is increasingly congested. Western foreign policies have shifted towards pro-active stabilisation agendae and so Civil-Military Relationships (CMRel) will inevitably be more frequent. Debate is hampered by lack of a common language or clear, mutually understood operational contexts to define such relationships. Often it may be easier to simply assume that military co-operation attempts are solely to 'win hearts and minds', rather than attempt to navigate the morass of different acronyms. In healthcare, such relationships are common and more complex - partly as health is seen as both an easy entry point for diplomacy and so is a priority for militaries, and because health is so critical to apolitical humanitarian responses. This paper identifies the characteristics of commonly described kinds of CMRel, and then derives a typology that describe them in functional groups as they apply to healthcare-related contexts (although it is likely to be far more widely applicable). Three broad classifications are described, and then mapped against 6 axes; the underlying military and civilian motivations, the level of the engagement (strategic to tactical), the relative stability of the geographical area, and finally the alignment between the civilian and military interests. A visual representation shows where different types may co-exist, and where they are likely to be more problematic. The model predicts two key areas where friction is likely; tactical interactions in highly unstable areas and in lower threat areas where independent military activity may undermine ongoing civilian programmes. The former is well described, supporting the typology. The latter is not and represents an ideal area for future study. In short, we describe an in-depth typology mapping the Civil-Military space in humanitarian and development contexts with a focus on healthcare, defining operational spaces and the identifying of areas of synergy and friction.

Medical civil-military interactions on United Nations missions: lessons from South Sudan.

This paper outlines the United Nations' integrated response to complex humanitarian emergencies and the different types of interactions that may occur between militaries and civilian organisations involved in them. It uses a recent UK deployment to South Sudan as an example, drawing on the experience to highlight areas of particular interest to healthcare workers. It identifies several domains that should usefully be developed for both civilians and military personnel in these environments-including sharing our expertise in major incident management, proof-of-concept testing for novel diagnostic and treatment solutions and offering to engage in joint continuing medical education. These gaps in organisational policy should be addressed and appropriate training pathways designed to maximise the contribution of the Defence Medical Services in similar contexts in the future.

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.

An outbreak inside an epidemic: managing an infectious disease outbreak while treating Ebola.

Even in the middle of an epidemic of a very serious illness, outbreaks of other infectious diseases will continue. Clinicians need to be able to make rapid decisions about the nature of the outbreak and how to manage it. A balance needs to be struck between managing all patients as if they have the worst-case scenario illness and the resultant risks to themselves, their colleagues and the mission. This paper reviews basic epidemiological tools that inform robust decision-making in the management of such outbreaks. It then describes how a pragmatic approach, combined with effective use of these techniques, rapid diagnostics and remote specialist support, allowed a large outbreak of gastroenteritis to be safely and effectively managed during the response to the Ebola virus disease epidemic in Sierra Leone.

You Can't Make a Silk Purse Out of a Sow's Ear: Time to Start Again with MCI Triage.

Horne S , Nutbeam T . You can't make a silk purse out of a sow's ear: time to start again with MCI triage. Prehosp Disaster Med. 2016;31(4):459-460.

A Health Care Worker with Ebola Virus Disease and Adverse Prognostic Factors Treated in Sierra Leone.

We describe the management of a Sierra Leonean health care worker with severe Ebola virus disease complicated by diarrhea, significant electrolyte disturbances, and falciparum malaria coinfection. With additional resources and staffing, high quality care can be provided to patients with Ebola infection and adverse prognostic factors in west Africa.

Triage in the defence medical services.

Triage of patients into categories according to their need for intervention is a core part of military medical practice. This article reviews how triage has evolved in the Defence Medical Services and how it might develop in the context of recent research. In particular, a simple model demonstrates that the ideal sensitivity and specificity of a triage system depends upon the availability of transport and the capacity of the receiving units. As a result, we may need to fundamentally change the way we approach triage in order to optimise outcomes-especially if casualty evacuation timelines become longer and smaller medical units more prevalent on future operations. Some pragmatic options for change are discussed. Finally, other areas of current research around triage are highlighted, perhaps showing where triage may go next.

UK Triage the validation of a new tool to counter an evolving threat.

INTRODUCTION: Major Incidents (MI) occur frequently and their unpredictable nature makes prospective research difficult and largely unethical. A key step in MI management is triage; the identification of the critically injured. Within a MI environment this is commonly performed using simple physiological 'tools', such as the Triage Sieve (TS). However the most commonly used tools appear to lack an evidence base. In a previous study, the authors used a military population to compare the performance of the TS to the Military Sieve (MS) at predicting need for Life-Saving Intervention (LSI). The MS differs only with the addition of a measurement of consciousness. The outcome from this study was that the MS outperformed the TS, but could be further improved with small changes to its physiological parameters, the Modified Military Sieve (MMS). MATERIALS AND METHODS: Physiological data and interventions performed within the Emergency Department (ED) and Operating Theatre were prospectively collected for consecutive adult trauma patients (>18years) presenting to the ED at Camp Bastion, Afghanistan between March and September 2011. All patients receiving a LSI were considered Gold Standard Priority One. Patients were triaged using the TS, MS, MMS, START (ST) and Careflight (CF) triage tools. Sensitivities and specificities were estimated with 95% confidence intervals and differences were checked for statistical significance using a McNemar test with Bonferroni correction. RESULTS: 482 patients presented to the ED during the study period, sufficient data was recorded for 335 (71%) with 199 (59%) P1s. The MMS (sensitivity 68.3%, specificity 79.4%) showed an absolute increase in sensitivity over existing tools ranging from 5.0% (MS) to 23.6% (CF). There was a statistically significant difference (P = 0.0005) between the MMS and MS. DISCUSSION: A key limitation to this study, is the use of a military cohort to validate the MMS, a tool which itself was developed using military data. The mechanism of injury also is unlikely to translate fully to the civilian population. CONCLUSIONS: Within a military population, the MMS outperforms existing MI triage tools. Before it is recommended as a replacement to the existing TS in UK civilian practice, it needs to be tested in a civilian environment.

Treatment and prevention of Mycobacterium ulcerans infection (Buruli ulcer) in Australia: guideline update.

• Guidelines reflecting contemporary clinical practice in the management of Buruli ulcer (Mycobacterium ulcerans infection) in Australia were published in 2007. • Management has continued to evolve, as new evidence has become available from randomised trials, case series and increasing clinical experience with oral antibiotic therapy. • Therefore, guidelines on the diagnosis, treatment and prevention of Buruli ulcer in Australia have been updated. They include guidance on the new role of antibiotics as first-line therapy; the shortened duration of antibiotic treatment and the use of all-oral antibiotic regimens; the continued importance, timing and role of surgery; the recognition and management of paradoxical reactions during antibiotic treatment; and updates on the prevention of disease.

UK triage--an improved tool for an evolving threat.

INTRODUCTION: A key challenge at a major incident is to quickly identify those casualties most urgently needing treatment in order to survive - triage. The UK Triage Sieve (TS) advocated by the Major Incident Medical Management (MIMMS) Course categorises casualties by ability to walk, respiratory rate (RR) and heart rate (HR) or capillary refill time. The military version (MS) includes assessment of consciousness. We tested whether the MS better predicts need for life-saving intervention in a military trauma population. Ideal HR, RR and Glasgow Coma Score (GCS) thresholds were calculated. METHODS: A gold standard Priority 1 casualty was defined using resource-based criteria. Pre-hospital data from a military trauma database allowed calculation of triage category, which was compared with this standard, and presented as 2×2 tables. Sensitivity and specificity of each physiological parameter was calculated over a range of values to identify the ideal cut-offs. RESULTS: A gold standard could be ascribed in 1657 cases. In 1213 both the MS and TS could ascribe a category. MS was significantly more sensitive than TS (59% vs 53%, p<0.001) with similar specificity (89 vs 88%). Varying the limits for each parameter allowed some improvements in sensitivity (70-80%) but specificity dropped rapidly. DISCUSSION: Previous studies support the inclusion of GCS assessment for blunt as well as penetrating trauma. Optimising the physiological cut-offs increased sensitivity in this sample to only 71% - a Sieve based purely on physiological parameters may not be capable of an acceptable level of sensitivity. CONCLUSIONS: The MS is more sensitive than the TS. Major incident planners utilising the Sieve should consider adopting the military version as their first line triage tool. If validated, altering the HR and RR thresholds may further improve the tool.

Psoas abscess secondary to haematoma after a fall causing multiple osteoporotic fractures.

A 78-year-old woman presented 28 days after a low-impact fall, where she sustained a right pubic ramus fracture, with increasing left hip pain and fever. Her blood results showed a high white cell count and deranged urea and electrolytes. An MRI revealed multiple osteoporotic fractures and bilateral gluteal abscesses with left iliopsoas abscess, which had likely formed in a haematoma of a sacral fracture. She received a long course of intravenous antibiotics and CT-guided drainage of the abscesses. She developed symptoms of cauda equina, but no evidence of epidural extension of the abscess was found at operation. She required neurorehabilitation. This case highlights the complications of pelvic osteoporotic fractures, and high associated morbidity and mortality in the elderly population.

Ultrasound triage of ocular blast injury in the military emergency department.

INTRODUCTION: Ultrasound (US) provides rapid effective assessment of the globe. In Afghanistan, ocular blast injuries are common. We present a case series demonstrating the value of US in this context. METHODS: 29 patients with suspected blast eye injury had both computed tomography (CT) of the head and ocular US as part of their standard care in a military hospital in Afghanistan. The US images were assessed by blinded consultants (emergency department and radiology) and compared with the CT reports. RESULTS: 18 patients had an intraocular injury on either CT or US. CT identified 11 injuries. US detected 18, including all 11 detected by CT. Inter-rater agreement was high (28/29). DISCUSSION: This series suggests that US may be as good as CT at detecting ocular blast injuries. However, inability to follow up local national patients meant that the clinical relevance of these findings cannot be quantified. US is likely to have a role on deployed operations in triaging possible ocular injuries. CONCLUSIONS: US is an easy, cheap alternative to CT for the assessment of blast injury to the eye. It appears to have identified all injuries detected by CT in this series and can be accurately interpreted by emergency physicians.