Reviewing the needs of forward deployed critical care: South Sudan and the future.

The UK military medical treatment facility (MTF) that deployed to the United Nations Mission in South Sudan in 2017 was based on a facility that can provide damage control surgery and resuscitation for soldiers with ballistic trauma injuries. It had to be supplemented with additional medical equipment and drugs that could support a peacekeeping mission in Africa. The clinicians used this experience and opportunity to review the critical care capability of UK Army Medical Services forward MTFs and recommend changes to reflect the increasing contemporaneous need on recent deployments to support more casualties with medical, infectious diseases and other non-battle injuries and illnesses. A concurrent review of the facility's critical care transfer equipment was also undertaken and allowed it to be adapted for use as either transfer equipment or as a critical care surge capability, to increase the facility's critical care capacity.

Novel equipment used in the UK Role 2 medical treatment facility as part of Operation TRENTON in South Sudan.

The deployment of a UK military Role 2 Medical Treatment Facility (MTF) to South Sudan during Operation TRENTON into an isolated location and austere environment with a prolonged hold produced potential medical planning challenges. The MTF was augmented with both specific personnel and equipment in order to meet these challenges. This paper discusses equipment available in this facility not previously used at Role 2 before and how it could be used to supplement medical operational deployments in future.

Medical support to military airborne training and operations.

INTRODUCTION: Airborne operations enable large numbers of military forces to deploy on the ground in the shortest possible time. This however must be balanced by an increased risk of injury. The aim of this paper is to review the current UK military drop zone medical estimate process, which may help to predict the risk of potential injury and assist in planning appropriate levels of medical support. METHOD: In spring 2015, a British Airborne Battlegroup (UKBG) deployed on a 7-week overseas interoperability training exercise in the USA with their American counterparts (USBG). This culminated in a 7-day Combined Joint Operations Access Exercise, which began with an airborne Joint Forcible Entry (JFE) of approximately 2100 paratroopers.The predicted number of jump-related injuries was estimated using Parachute Order Number 8 (PO No 8). Such injuries were defined as injuries occurring from the time the paratrooper exited the aircraft until they released their parachute harness on the ground. RESULTS: Overall, a total of 53 (2.5%) casualties occurred in the JFE phase of the exercise, lower than the predicted number of 168 (8%) using the PO No 8 tool. There was a higher incidence of back (30% actual vs 20% estimated) and head injuries (21% actual vs 5% estimated) than predicted with PO No 8. CONCLUSION: The current method for predicting the incidence of medical injuries after a parachute drop using the PO No 8 tool is potentially not accurate enough for current requirements. Further research into injury rate, influencing factors and injury type are urgently required in order to provide an evidence base to ensure optimal medical logistical and clinical planning for airborne training and operations in the future.

Early cryoprecipitate for major haemorrhage in trauma: a randomised controlled feasibility trial.

BACKGROUND: Low fibrinogen (Fg) concentrations in trauma haemorrhage are associated with poorer outcomes. Cryoprecipitate is the standard source for Fg administration in the UK and USA and is often given in the later stages of transfusion therapy. It is not known whether early cryoprecipitate therapy improves clinical outcomes. The primary aim of this feasibility study was to determine whether it was possible to administer cryoprecipitate, within 90 min of admission to hospital. Secondary aims were to evaluate laboratory measures of Fg and clinical outcomes including thrombotic events, organ failure, length of hospital stay and mortality. METHODS: This was an unblinded RCT, conducted at two civilian UK major trauma centres of adult trauma patients (age ≥16 yrs), with active bleeding and requiring activation of the major haemorrhage protocol. Participants were randomised to standard major haemorrhage therapy (STANDARD) (n=22), or to standard haemorrhage therapy plus two early pools of cryoprecipitate (CRYO) (n=21). RESULTS: 85% (95% CI: 69-100%) CRYO participants received cryoprecipitate within 90 min, median time 60 min (IQR: 57-76) compared with 108 min (67-147), CRYO and STANDARD arms respectively (P=0.002). Fg concentrations were higher in the CRYO arm and were maintained above 1.8 g litre(-1) at all time-points during active haemorrhage. All-cause mortality at 28 days was not significantly different (P=0.14). CONCLUSIONS: Early Fg supplementation using cryoprecipitate is feasible in trauma patients. This study supports the need for a definitive RCT to determine the effect of early Fg supplementation on mortality and other clinical outcomes. TRIAL REGISTRY NUMBER: ISRCTN55509212.

Paediatric trauma management on deployment.

There remains a significant paediatric workload through the military hospital in Camp Bastion. In this paper the authors review and discuss particular problems with resuscitation, investigation, anaesthetic and surgical issues in dealing with children suffering from ballistic injuries. Personal experience and recent papers are used for a qualitative analysis of difficult decisions in the management of paediatric ballistic trauma. Key questions are answered in separate paragraphs for each specialty. The information described in this paper should assist any deployed physician deal with paediatric casualties particularly if they are unaccustomed to paediatric patients in their normal practice.

Paediatric anaesthesia in Afghanistan: a review of the current experience.

This paper describes the author's experience of the paediatric patient load on the U.K. medical services in Afghanistan. Over a 3 month period there was a mean of 2.9 paediatric trauma admissions per week, mean age was 6.8 years with gunshot wound or explosive injury being the mechanisms of injury in 77% of the trauma admissions. Overall these children represented 10.8% of the surgical workload. Some of the issues of paediatric anaesthesia in this environment are discussed including paediatric equipment, resuscitation for paediatric massive haemorrhage and regional anaesthesia. The need to formally recognise the problem in training and equipping deployed medical personnel to deal with this challenge is examined.

The paediatric transfusion challenge on deployed operations.

This paper briefly touches on the problem of dealing with the severely injured child requiring massive transfusion and produces a guide on the management of this based on the current Surgeon General's Operational Policy Letter. There are no known UK guidelines on massive transfusion in trauma in the paediatric population although many specialist centres have guidance for dealing with cases in theatre during elective surgery. It is hoped that these guidelines will be used by deployed military anaesthetists to aid in their management of these difficult cases, not normally seen in the U.K.

Emergence and recovery in children after desflurane and isoflurane anaesthesia: effect of anaesthetic duration.

BACKGROUND: We hypothesized that increasing duration of inhalation anaesthesia is associated with slower emergence and recovery in children, and that this effect would be less marked with desflurane in comparison with isoflurane. METHODS: Fifty-four infants and children assigned in groups according to age and expected length of operation were prospectively randomized to receive either isoflurane (I) or desflurane (D) for anaesthesia. After standard induction, the anaesthesia was maintained using an age-related 1.0 minimum alveolar concentration (MAC) equivalent for either agent in air and oxygen. Local analgesia was used as appropriate. End-tidal volatile agent concentration was recorded until extubation. Clinical evaluation of recovery was made by observers, blinded to group allocation. RESULTS: For patients <4 yr of age, the median (95% CI) times in minutes to first movement [5.27 (D), 9.22 (I)], eye opening [9.42(D), 13.3(I)] and extubation [7.18 (D), 12.5 (I)] were significantly shorter (P<0.05) for desflurane. In the group >4 yr of age, the median (95% CI) times in minutes to first movement [4.42 (D), 11.6 (I)], eye opening [8.55(D), 18.0(I)] and extubation [7.08 (D), 16.7 (I)] were significantly shorter (P<0.001) for desflurane. Times to leave recovery were not significantly different for the group <4 yr of age, but were significantly shorter for desflurane in the group >4 yr of age (P<0.01). The isoflurane, but not desflurane, had a time-dependent effect on arousal. There were no significant differences in incidence of airway irritation or emergence delirium between the two agents. CONCLUSIONS: The rate of recovery in children after exposure to desflurane was faster than those patients receiving isoflurane; recovery from desflurane, but not isoflurane, was relatively unaffected by the duration of anaesthesia.

The deployment of an intensive care facility with a military field hospital to the 2003 conflict in Iraq.

The deployment of an intensive care unit with a forward British military field hospital to the conflict in Iraq in March 2003 is described. The 10 bedded unit treated 47 patients in the first month of activity. Thirty seven were adults and 10 were children. Forty two (89%) were trauma patients, mostly related to the conflict. Sixty eight percent of patients were ventilated and mortality to discharge was 6%. Mean bed occupancy was five beds and the mean duration of patient stay was 3.3 days. The difficulties of the working environment are described including the problems of a desert climate and close proximity to a conflict. Several critical incidents occurred including total power failure, extreme ambient temperatures and gas attack alarms. Despite these challenges, the facility attempted to provide a standard of intensive care similar to that seen in UK practice.

Highly efficient synthesis of linear pyrrole oligomers by twofold Heck reactions.

The twofold Heck reaction of the vinylpyrroles 3a and 3b with the iodobenzenes 4a-c led to the linear pyrrole oligomers 5, 6, and 7. The synthesis of both symmetrical and unsymmetrical oligomers, such as 10a and 10b, was also accomplished by a Heck reaction of 8 and 9 and by a Heck reaction of 3a and 11 followed by a Wittig reaction and a second Heck reaction with 8. The pentacyclic oligomers 14 and 19 were prepared by a twofold Heck reaction of 13 with 4 and by a twofold Heck reaction of 15 with 16 followed by a Wittig reaction and a twofold Heck reaction with 8.