Authors:
Loessel, C; Mai, A, Starke, M, Vogt, D, Stichling, M, Willy, C. Pages: 8 - 17 Abstract: AimCombat-related extremity injuries are regularly associated with long-term complications such as chronic infection, especially osteomyelitis. Clinical examination and laboratory parameters do not usually allow reliable diagnosis. In contrast, imaging techniques enable constructive assertions to be made about the location and extent of an infection of the peripheral musculoskeletal system. The aim of this study was therefore to determine the diagnostic reliability of three-phase bone scanning and antigranulocyte scintigraphy using Tc-99m-sulesomab (Leukoscan) in the diagnostic clarification of infections associated with combat-related extremity injuries.MethodsTwenty-seven male patients (mean age 33.9 years) with suspected combat-associated infections of the extremities were included in this retrospective analysis. All patients underwent three-phase bone scanning using Tc-99m-HDP followed by antigranulocyte scintigraphy with Tc-99m-sulesomab. In 26 of the 27 patients, a CT scan of affected limb was obtained, where the secondary fusion with single photon emission CT data set was possible. The diagnostic reliability of imaging techniques was validated against microbiological samples obtained during surgery and used as gold standard.ResultsThree-phase bone scanning yielded a positive result in all patients, with 18 scans classified as true positive (TP) and nine scans as false positive (FP). This produced a sensitivity of 100%, a specificity of 0% and a positive predictive value (PPV) of 67%. Antigranulocyte scintigraphy recognised 13 patients as TP, 1 patient as FP, 8 patients as true negative (TN) and 5 patients as false negative (FN), which gave a sensitivity of 72%, a specificity of 88%, a PPV of 93%, a negative predictive value (NPV) of 62% and an accuracy of 78%. CT recognised in 7 cases a TP result, in 3 cases an FP, in 5 cases a TN and in 11 cases an FN result. This produced a sensitivity of 39%, a specificity of 63%, a PPV of 70%, an NPV of 31% and an accuracy of 46%.ConclusionsThree-phase bone scanning did not deliver any diagnostic benefit, since no result was able to differentiate unequivocally between infection-related and reactive changes. Antigranulocyte scintigraphy using Tc-99m-sulesomab represented a highly suitable technique for diagnostically clarifying combat-related infections of the extremities. It is superior to CT in sensitivity, specificity, PPV, NPV and accuracy. Keywords: Open access PubDate: 2021-01-25T05:10:35-08:00 DOI: 10.1136/jramc-2019-001172 Issue No:Vol. 167, No. 1 (2021)
Authors:
Campbell, K; Naumann, D. N, Remick, K, Wright, C. Pages: 18 - 22 Abstract: IntroductionSpecialist units that assist indigenous forces (IF) in their strategic aims are supported by medical teams providing point of injury emergency care for casualties, including IF and civilians (Civ). We investigated the activities of a Coalition Forces far-forward medical facility, in order to inform medical providers about the facilities and resources required for medical support to IF and Civ during such operations.MethodsA prospective observational study (June to August 2017) undertaken at a far-forward Coalition Forces medical support unit (12 rotating personnel) recorded patient details (IF or Civ), mechanism of injury (MOI), number of blood products used, damage control resuscitation (DCR) and damage control surgery (DCS), number of mass casualty (MASCAL) scenarios, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA) and whole blood emergency donor panels (EDP).Results680 casualties included 478 IF and 202 Civ (45.5% of the Civ were paediatric). Most common MOIs were blast (n=425; 62.5%) and gunshot wound (n=200; 29.4%). Fifteen (2.2%) casualties died; 627 (92.2%) were transferred to local hospitals. DCR was used for 203 (29.9%), and DCS for 182 (26.8%) casualties. There were 23 MASCAL scenarios, 1220 transfusions and 32 EDPs. REBOA was performed eight times, and thoracotomy was performed 27 times.ConclusionsA small medical team provided high-tempo emergency resuscitative care for hundreds of IF and Civ casualties within a short space of time using state-of-the-art resuscitative modalities. DCR and DCS were undertaken with a large number of EDPs, and a high survival-to-transfer rate. PubDate: 2021-01-25T05:10:35-08:00 DOI: 10.1136/jramc-2019-001228 Issue No:Vol. 167, No. 1 (2021)
Authors:Lillywhite L. Pages: 23 - 26 Abstract: Alleged and confirmed abuse of civilians arrested or detained by the UK Armed Forces has been the subject of four formal enquiries, and all have used medical evidence and/or addressed medical issues. After the first three, robust policies were put in place to ensure that all those arrested had appropriate medical examinations and that healthcare personnel acted appropriately. However, by the time of the Second Gulf War, the training and medical processes had lapsed and were found to be a contributory factor in not preventing abuse. The fourth enquiry has endorsed most of the lapsed policies but is ambiguous in two areas—on medical certification of fitness for interrogation and the timing to the first medical examination. This article summarises the medical aspects of the four enquiries and discusses the two ambiguous areas, arguing that to diverge from the policies eventually put in place in Northern Ireland is a retrograde step. It also discusses how training put in place to avoid the very events which occurred in the Second Gulf was discontinued. Keywords: Editor''s choice PubDate: 2021-01-25T05:10:35-08:00 DOI: 10.1136/jramc-2019-001156 Issue No:Vol. 167, No. 1 (2021)
Authors:
Taylor, N; Gifford, R. M, Cobb, R, Wardle, S. L, Jones, S, Blackadder-Weinstein, J, Hattersley, J, Wilson, A, Imray, C, Greeves, J. P, Reynolds, R, Woods, D. R. Pages: 27 - 32 Abstract: IntroductionExpedition ICE MAIDEN (Ex IM) was the first all-female unsupported crossing of Antarctica. We describe the prerequisite selection and training, comparing those who formed the final team with other participants, and discuss how the expedition diet was established.MethodsAll women serving in the British Army were invited to participate. Following initial assessments, successful women completed three training/selection ski expeditions. Between expeditions 1 and 2, participants completed 6 months rigorous UK-based training. Weight was measured before and after the 6 months UK-based training, expeditions 2 and 3, and body composition by skinfold before and after expedition 2. Participant feedback, body composition and weight changes were applied to modify the expedition diet and provide weight gain targets prior to Ex IM.ResultsFollowing 250 applications, 50 women were assessed and 22, 12 and seven women attended training expeditions 1, 2 and 3, respectively. The final team of six women lost more weight than other participants during UK-based training (mean (SD) change –1.3 (1.5) kg vs –0.5 (1.6) kg, respectively, p=0.046) and during training expedition 2 (–2.8 (0.8) kg vs –1.7 (0.4) kg, respectively, p=0.048), when they also gained more lean mass (+2.1 (0.8) kg vs +0.4 (0.7) kg, respectively, p=0.004). The Ex IM diet provided 5000 kCal/day, comprising approximately 45% carbohydrate, 45% fat and 10% protein. Median (range) weight change between expedition 3 and Ex IM was +8.7 (–1.9 to +14.3) kg.ConclusionsThe selected Ex IM team demonstrated favourable training-associated body composition changes. Training-associated weight loss informed the expeditionary diet design. PubDate: 2021-01-25T05:10:35-08:00 DOI: 10.1136/jramc-2019-001175 Issue No:Vol. 167, No. 1 (2021)
Authors:
Swiech, A; Boddaert, G, Daban, J.-L, Falzone, E, Ausset, S, Boutonnet, M. Pages: 33 - 39 Abstract: BackgroundPenetrating thoracic injuries (PTIs) is a medicosurgical challenge for civilian and military trauma teams. In civilian European practice, PTIs are most likely due to stab wounds and mostly require a simple chest tube drainage. On the battlefield, combat casualties suffer severe injuries, caused by high-lethality wounding agents.The aim of this study was to analyse and compare the demographics, injury patterns, surgical management and clinical outcomes of civilian and military patients with PTIs.MethodsAll patients with PTIs admitted to a Level I Trauma Centre in France or to Role-2 facilities in war theatres between 1 January 2004 and 31 May 2016 were included. Combat casualties’ data were analysed from Role-2 medical charts. The hospital manages military casualties evacuated from war theatres who had already received primary surgical care, but also civilian patients issued from the Paris area. During the study period, French soldiers were deployed in Afghanistan, in West Africa and in the Sahelo-Saharan band since 2013.Results52 civilian and 17 military patients were included. Main mechanisms of injury were stab wounds for civilian patients, and gunshot wounds and explosive fragments for military casualties. Military patients suffered more severe injuries and needed more thoracotomies. In total, 29 (33%) patients were unstable or in cardiac arrest on admission. Thoracic surgery was performed in 38 (55%) patients (25 thoracotomies and 13 thoracoscopies). Intrahospital mortality was 18.8%.ConclusionWar PTIs are associated with extrathoracic injuries and higher mortality than PTIs in the French civilian area. In order to reduce the mortality of PTIs in combat, our study highlights the need to improve tactical en route care with transfusion capabilities and the deployment of forward surgical units closer to the combatants. In the civilian area, our results indicated that video-assisted thoracoscopic surgery is a reliable diagnostic and therapeutic technique for haemodynamically stable patients. PubDate: 2021-01-25T05:10:35-08:00 DOI: 10.1136/jramc-2019-001159 Issue No:Vol. 167, No. 1 (2021)
Authors:
Lopes-Joao, A; Mesquita, J. R, de Sousa, R, Oleastro, M, Penha-Goncalves, C, Nascimento, M. S. J. Pages: 40 - 43 Abstract: IntroductionNorovirus outbreaks frequently occur in communities and institutional settings acquiring a particular significance in armed forces where prompt reporting is critical. Here we describe the epidemiological, clinical and laboratorial investigation of a multicentre gastroenteritis outbreak that was detected simultaneously in three Portuguese army units with a common food supplier, Lisbon region, between 5 and 6 December 2017.MethodsQuestionnaires were distributed to all soldiers stationed in the three affected army units, and stool specimens were collected from soldiers with acute gastrointestinal illness. Stool specimens were tested for common enteropathogenic bacteria by standard methods and screened for a panel of enteric viruses using a multiplex real-time PCR assay. Food samples were also collected for microbiological analysis. Positive stool specimens for norovirus were further genotyped.ResultsThe three simultaneous acute gastroenteritis outbreaks affected a 31 (3.5%) soldiers from a total of 874 stationed at the three units and lasted for 2 days. No secondary cases were reported. Stool specimens (N=11) were negative for all studied enteropathogenic agents but tested positive for norovirus. The recombinant norovirus GII.P16-GII.4 Sydney was identified in all positive samples with 100% identity.ConclusionsThe results are suggestive of a common source of infection plausibly related to the food supplying chain. Although centralisation of food supplying in the army has economic advantages, it may contribute to the multifocal occurrence of outbreaks. A rapid intervention is key in the mitigation of outbreak consequences and in reducing secondary transmission. PubDate: 2021-01-25T05:10:35-08:00 DOI: 10.1136/jramc-2019-001242 Issue No:Vol. 167, No. 1 (2021)
Authors:
Halle-Smith, J. M; Ahmad, T, Mason, G, Barlow, A, Gout, S. Pages: 44 - 47 Abstract: IntroductionThe Medical Reception Station (MRS) in Dhekelia provides a prehospital emergency care (PHEC) service for the Eastern Sovereign Base Area and surrounding Cypriot towns. This service has been evaluated previously but some important aspects of care have not yet been measured. The primary aim of this study was to undertake the most comprehensive service evaluation of the demand for the PHEC service at MRS Dhekelia over a 12-month period. The secondary aim of this study was to compare findings in 2018 to those in 1995–1998 and 2013–2016.MethodsAll calls to the PHEC team between 01/07/2017 and 30/06/2018 were reviewed and compared with previously reported data from 1995 to 1998 and 2013 to 2016. Data were collected from the occurrence book, the logbook used by the PHEC team to record the details of each call.ResultsThere were 164 calls to the PHEC service during the current study period. The number of activations has decreased since the 2013–2016 period but remains greater than 1995–1998. In every month there was a call to a scene where more than one casualty was present, with the highest number being nine patients at one call. More calls were received during the day (55%). There were more calls because of trauma than medical complaints (55% vs 45%). Trauma calls have reduced over 20 years. The frequency of neurological and psychiatric complaints has increased over 20 years.ConclusionsThe PHEC service at MRS Dhekelia is frequently used. The team consistently face with scenes with more than one casualty. Trauma is becoming less frequent but psychiatric and neurological complaints are increasingly common. These findings are important for training and service provision. PubDate: 2021-01-25T05:10:35-08:00 DOI: 10.1136/jramc-2019-001221 Issue No:Vol. 167, No. 1 (2021)
Authors:
Ajri-khameslou, M; Aliyari, S, Pishgooie, A. H, Jafari-Golestan, N, Farokhnezhad Afshar, P. Pages: 48 - 52 Abstract: Background and objectivesNursing errors can cause irreparable consequences. Understanding the concept of error and the nature of nursing error detectors can significantly reduce this type of errors. The present study was conducted to explain the concept of error and the nature of nursing error detectors in military hospitals.Materials and methodsThe present study was conducted on eight nurses working in different wards of military hospitals using a qualitative approach to content analysis proposed by Graneheim and Lundman. Data were collected through in-depth semistructured interviews.Findings‘The concept of error’ and ‘the nature of error detectors’ in military hospitals were the two main categories extracted from data analysis. The present findings showed that the nature of errors in military hospitals is inevitable, a threat to job position and bipolar. Nurses use different resources to identify errors, including personal, environmental and organisational factors of detection.Discussion and conclusionGiven the military nature of the study hospitals, organisational factors of detection played a key role in identifying errors. Moreover, given the perception of military nurses of errors, they were not inclined to personal detectors. The managers of military hospitals are therefore recommended to pursue a justice-oriented and supportive culture to help nurses play a more active role in identifying errors. PubDate: 2021-01-25T05:10:35-08:00 DOI: 10.1136/jramc-2019-001198 Issue No:Vol. 167, No. 1 (2021)
Authors:Wilkins D. Pages: 53 - 55 Abstract: The British Army has a long history of training in Kenya, including delivering health outreach to the local population on Exercise ASKARI SERPENT. This article presents data from two iterations of Exercise ASKARI SERPENT in which children accounted for almost 40% of all patients treated. Short case vignettes highlight the technical and non-technical challenges faced when treating children, before recommendations are made for pre-deployment training for Exercise ASKARI SERPENT and similar future deployments which may see military clinicians delivering treatment to the local population. PubDate: 2021-01-25T05:10:35-08:00 DOI: 10.1136/jramc-2019-001258 Issue No:Vol. 167, No. 1 (2021)
Authors:
Rabener, M. J; Breeze, J. Pages: 56 - 58 Abstract: Physicians assistants (PAs) are being increasingly utilised by the US Armed Forces both in homeland medical treatment provision as well as while on deployment. In a deployed environment, the USA has the flexibility to interchange doctors with specialty-trained PAs in all roles of care due to their ability to practice autonomously, thereby filling shortfalls created by the lack of specialty physicians. PAs are increasingly being utilised within the UK National Health Service, in similar roles to their US counterparts. This paper postulates that PAs have an equivalent role to play in the future of medical care provision within the UK Defence Medical Services, including on military operations. PubDate: 2021-01-25T05:10:35-08:00 DOI: 10.1136/jramc-2019-001298 Issue No:Vol. 167, No. 1 (2021)
Authors:
Queiros-Reis, L; Lopes-Joao, A, Mesquita, J. R, Penha-Goncalves, C, Nascimento, M. S. J. Pages: 59 - 62 Abstract: IntroductionNorovirus gastroenteritis is one of the most frequent causes of personnel unavailability in military units, being associated with significant morbidity and degradation of their operational effectiveness. The disease is usually mild but can be severe and life-threatening in young and healthy soldiers, who are prone to dehydration due to intensive daily activity. Despite its impact, the full extent of the norovirus gastroenteritis burden in military forces remains unclear. This systematic review aims to evaluate the impact and ascertain clinical and epidemiological features of norovirus outbreaks that have occurred in the military forces.MethodsThe systematic review followed the Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) guidelines and used three databases: PubMed, Scopus, and LILACs. Papers published up to 1 September 2019 were included without restrictions if they reported one or more outbreaks in the military forces on active duty, either on national territories or deployed overseas.ResultsA total of 343 papers were retrieved from the literature search. After inclusion/exclusion criteria a total of 39 eligible papers were considered. From 1988 (first reported outbreak in the military) to 2018 more than 101 norovirus outbreaks have been reported in the military, accounting for at least 24 332 cases. Secondary transmission was emphasised as the main route of norovirus transmission in the military forces, with eating outside the military setting an important route for the primary cases.ConclusionsThe present review highlights that norovirus gastroenteritis has been a burden to military troops both in combat and on peacekeeping operations. Norovirus disease has been shown to exact a substantial toll on mission readiness and operational effectiveness. It is noteworthy that the impact of norovirus outbreaks among military units is underestimated because the literature review retrieved information from the armed forces from only nine countries. PubDate: 2021-01-25T05:10:35-08:00 DOI: 10.1136/bmjmilitary-2019-001341 Issue No:Vol. 167, No. 1 (2021)
Authors:
Harden, L; Jones, N, Whelan, C, Phillips, A, Simms, A, Greenberg, N. Pages: 63 - 69 Abstract: IntroductionPredeployment stress management/mental health training is routinely delivered in an effort to mitigate potential adverse psychological effects. Little is known about the effectiveness of such interventions.MethodsA systematic literature review explored research outcomes related to this subject, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. An electronic database search using key terms identified studies published between January 2007 and March 2019. Comprehensive inclusion/exclusion criteria were applied and study quality was appraised by two reviewers using 12 criteria adapted from the Critical Appraisal Skills Programme (CASP) checklist. Papers were excluded if they were allocated CASP scores ≤10 out of 24.Results2003 references were identified; 15 papers fulfilled inclusion criteria and quality threshold requirements. Included studies were randomised controlled trial design (n=8), quasi-experimental (n=5), case report (n=1) and cross-sectional (n=1). Duration of follow-up assessment varied from immediately postintervention to 24 months. The included studies were heterogeneous so clear recommendations relating to predeployment training for military personnel could not be made. Although somewhat disparate, predeployment interventions shared the aim of promoting prior to, during and after deployment health and well-being. Social benefits such as improved cohesion and improved stress management skills were identified in some studies, although substantial mental health and well-being benefits were not found.ConclusionsEvidence for the effectiveness of predeployment psychological interventions is scant. Every attempt should be made to use methods and measures to facilitate comparisons across studies, to attempt a longer follow-up timescale and to clarify key trainer characteristics. PubDate: 2021-01-25T05:10:35-08:00 DOI: 10.1136/bmjmilitary-2019-001296 Issue No:Vol. 167, No. 1 (2021)
Hybrid journal (It can contain Open Access articles)
