Authors:
Beaven, A; Sellon, E, Ballard, M, Parker, P. Pages: 75 - 79 Abstract: IntroductionThere is a need for a military tourniquet to control catastrophic haemorrhage in a chemical, biological, radiological or nuclear (CBRN) threat environment. No published data exist as to the efficacy of tourniquets while wearing British military CBRN individual protective equipment (IPE).Methods12 volunteers from the counter CBRN instructors’ course allowed testing on 24 legs. A Combat Application Tourniquet (C-A-T) was applied to all volunteers at the level of the midthigh. 12 legs were tested while wearing CBRN IPE (both operator and simulated casualty), and the control group of 12 legs was tested while wearing conventional combat dress state (both operator and simulated casualty). The order of leg laterality and dress state were sequenced according to a prerandomised system. Efficacy was measured via use of an ultrasound probe at the popliteal artery. Tourniquets were considered effective if arterial flow was completely occluded on ultrasound imaging. Data were collected on time to successful application, failure of tourniquets and pain scores as rated by the visual analogue scale (1–10).ResultsThere were no failures of tourniquet application in the CBRN group, and two failures (17%) in the control group. Failures were pain threshold exceeded (n=1) and tourniquet internal strap failure (n=1). The mean application time for the CBRN group was 28.5 s (SD 11.7) and 23.7 s (SD 9.8) for the conventional combat group. There was no statistically significant difference (p=0.27). The median CBRN pain score was 2.0 (IQR 2.0–3.5). The median control pain score was 4.0 (IQR 3–6). This was a statistically significant difference (p=0.002).ConclusionC-A-Ts applied to simulated casualties in CBRN IPE at the midthigh are at least as efficacious as those applied to the midthigh in a conventional combat dress state. The pain experienced was less in CBRN IPE than when in a conventional combat dress state. PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/jramc-2019-001261 Issue No:Vol. 167, No. 2 (2021)
Authors:
Kim, K.-E; Kim, E.-J, Park, J, Kim, S, Kwon, J, Moon, G. Pages: 80 - 83 Abstract: IntroductionHumeral shaft fractures can lead to radial nerve injury and may require surgery and rehabilitation. We determined the causative events of humeral fracture, including arm wrestling, in young Korean soldiers and examined whether humeral fracture is related to demographic characteristics and the presence of radial nerve palsy.MethodsWe reviewed 7.5 years (July 2012 to June 2019) of medical records covering patients who had experienced a humeral shaft fracture after entering military service and had received surgery for open reduction and internal fixation. Data were obtained on basic demographics, initial event provoking the fracture, presence of radial nerve palsy, initial and follow-up severity of the weakness, and any discharge from military service because of prolonged radial nerve palsy.ResultsOf 123 cases, arm wrestling was the leading cause (52.8%). A high energy injury, such as falling from a height (11.4%), and sports related slips (10.6%) were other causes. All humeral shaft fractures caused by forceful contraction were spiral, while 40% of the fractures caused by external force related events were of a transverse type. The percentage of left-sided fractures was significantly higher for fractures arising from an external force than in those caused by forceful contraction related events. Radial nerve palsy was found in 34 patients (27.6%), and 16 were discharged from the military because of prolonged radial nerve palsy 6 months after the fracture. The causative events and other factors did not affect the presence of radial nerve palsy.ConclusionArm wrestling was the leading cause of humeral fracture in young Korean soldiers but the chance of developing comorbid radial nerve palsy did not differ from that of other causes. These epidemiologic findings in this young active group may help in understanding the causes of humeral shaft fracture in soldiers and in the wider young population. PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/bmjmilitary-2019-001373 Issue No:Vol. 167, No. 2 (2021)
Authors:
Webster, S; Barnard, E. B. G, Smith, J. E, Marsden, M. E. R, Wright, C. Pages: 84 - 88 Abstract: IntroductionThe majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care.MethodsThe UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004–2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR).Results2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5–75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%).In the KIA cohort, the median time to death was 0.0 (IQR 0.0–21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively. Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant.ConclusionOver two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase. Keywords: Editor''s choice PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/bmjmilitary-2020-001490 Issue No:Vol. 167, No. 2 (2021)
Authors:
Dehn, G; Hammer, N, Wyatt, M. C, Soltani, S. J, Kieser, D. C. Pages: 89 - 92 Abstract: IntroductionDisplaced unstable pelvic injuries are life threatening and require rapid reduction and stabilisation, typically achieved with an external fixator. Recently, the benefits of supra-acetabular pins have been proven; however, these are usually inserted under fluoroscopic guidance. In austere environments and in extremis, this facility is limited and fixation using anatomical landmarks is required. Thus, the aim of this study is to determine the relative position of the supra-acetabular bone to the crestal plane and examine its consistency in military-aged European personnel.MethodsA radiological review of 50 randomised pelvic CT scans in European patients aged 18–30 years from a Level 1 trauma centre was performed. The CT scans were analysed using 3D rendering software. The relative position of the supra-acetabular bone to the crestal plane was determined.ResultsThe supra-acetabular bone relative to the crestal plane was approximately 28° caudal and 24° medial to the crestal plane. The mean minimum distance from the pin’s entry point to the sciatic notch was approximately 73 mm. There were no differences noted between genders or hemipelvic side.ConclusionsThe supra-acetabular bone maintains a consistent relative position to the crestal plane. Thus, with the surgeon’s thumb on the anterior superior iliac spine (ASIS) and index finger on the iliac tubercle, defining the crestal plane, a supra-acetabular pin can be inserted into the anterior inferior iliac spine, which lies 3 cm inferior and 2 cm medial to the ASIS, and advanced along the supra-acetabular bone by angling the pin 30° caudal and 25° medial to the crestal plane. PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/jramc-2019-001251 Issue No:Vol. 167, No. 2 (2021)
Authors:
Smith, M; Johnston, K, Withnall, R. Pages: 93 - 98 Abstract: BackgroundThis article describes a novel patient care algorithm which provides a Role 1 (R1) medic with a structured approach to delivering prolonged field care (PFC) in a resource-limited environment. PFC is a vital component of the operational patient care pathway providing the continuum of care from completion of a primary survey to the delivery to hospital care. Future operational environments are likely to have more fragile or extended lines of communication, potentially delaying evacuation to hospital care. This delay may lead to increases in patient morbidity and mortality. Effective PFC offers an opportunity to improve patient outcomes and help mitigate against this risk.MethodsAn initial prototype model of a PFC care process was developed using existing hospital-based guidance. A series of medical and trauma vignettes and best available evidence were used to refine the algorithm.ResultsThe algorithm has been designed be used in conjunction with patient specific clinical guidance making the approach generalisable for all patient groups. For UK military, clinical guidance is provided by clinical guidelines for operations. The algorithm can be downloaded into a convenient format to be used on mobile devices or printed as an aide memoire. PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/jramc-2019-001224 Issue No:Vol. 167, No. 2 (2021)
Authors:
Boland, S. T; McInnes, C, Gordon, S, Lillywhite, L. Pages: 99 - 106 Abstract: The operational and policy complexity of civil-military relations (CMR) during public health emergencies, especially those involving militaries from outside the state concerned, is addressed in several guiding international documents. Generally, these documents reflect humanitarian perspectives and doctrine at the time of their drafting, and primarily address foreign military involvement in natural and humanitarian disasters. However, in the past decade, there have been significant changes in the geopolitical environment and global health landscapes. Foreign militaries have been increasingly deployed to public health emergencies with responses grounded in public health (rather than humanitarian) approaches, while public health issues are of increasing importance in other deployments. This paper reviews key international policy documents that regulate, guide or otherwise inform CMR in the context of recent events involving international CMR during public health emergency responses, grounded in analysis of a March 2017 Chatham House roundtable event on the subject. Major thematic concerns regarding the application of existing CMR guiding documents to public health emergencies became evident. These include a lack of consideration of public health factors as distinct from a humanitarian approach; the assertion of state sovereignty vis-à-vis the deployment of national militaries; the emergence of new armed, military and security groups and a lack of consensus surrounding the ‘principle of last resort’. These criticisms and gaps—in particular, a consideration for public health contexts and approaches therein—should form the basis of future CMR drafting or revision processes to ensure effective, safe, and sustainable CMR during public health emergency response. PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/bmjmilitary-2020-001505 Issue No:Vol. 167, No. 2 (2021)
Authors:
Greenberg, N; Cooke, J, Sullivan, E, Tracy, D. K. Pages: 107 - 109 Abstract: The COVID-19 pandemic has extracted an enormous physical health toll on many millions worldwide, and the wider societal impact from economic turmoil, unemployment, social isolation and so forth continue to be measured. A less explored aspect has been the psychological impact on treating healthcare staff, with emerging evidence of ‘moral injury’ and mental illness for some. This review explores the evidence base for implementing a tiered model of care to minimise this and foster ‘post-traumatic growth’, and describes the authors’ implementation of this in the London Nightingale hospital, with lessons for the armed forces. PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/bmjmilitary-2020-001624 Issue No:Vol. 167, No. 2 (2021)
Authors:
Ellington, M; Booker, R. J. Pages: 110 - 113 Abstract: Procedural sedation is defined as producing a state of reduced consciousness, where the patient is still able to respond to verbal or physical stimulus and to continuously maintain a patent airway and adequate ventilation. This can be done to facilitate treatment that would not be otherwise possible. Recent evidence, guidelines and new equipment introductions have improved the safety of procedural sedation at UK role 1 medical treatment facilities (MTFs). A role 1 MTF is defined by the North Atlantic Treaty Organization as a medical facility focusing on the provision of primary healthcare, specialised first aid, triage, resuscitation and stabilisation, and is usually staffed by a general practitioner or a general duties medical officer. This paper aims to update role 1 clinicians on the current evidence base and guidance regarding monitoring of patients during procedural sedation. PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/bmjmilitary-2019-001351 Issue No:Vol. 167, No. 2 (2021)
Authors:
Smith, S. A; McAlister, V. C, Dubois, L, Beckett, A, Hilsden, R. Pages: 114 - 117 Abstract: Tactical combat casualty care and the application of extremity tourniquets have saved lives in combat. In the modern combat environment junctional injuries are common and difficult to treat. Recently, junctional tourniquets have emerged as a potential solution to this problem. Junctional tourniquets can be used as an adjunct to persistent haemorrhage despite application of conventional tourniquets or in the persistently hypotensive casualty. Surgeons must have an approach to receiving patients with junctional tourniquets in place in the operating room. The algorithms presented allow for an evidence-based and command-driven implantation of junctional tourniquets as part of tactical combat casualty care. PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/bmjmilitary-2019-001336 Issue No:Vol. 167, No. 2 (2021)
Authors:
Bentley, C; Cooper, L, Foster, M, Fallowfield, J. Pages: 118 - 121 Abstract: The inclusion of British Service Personnel (SP) lacking capacity into research studies from the point of injury through to medium-term rehabilitation had not previously been undertaken until work to support operations in Afghanistan (2001–2014). The Surgeon General’s Casualty Nutrition Study and the Steroids and Immunity from Injury through to Rehabilitation Study sought to address the nutrition, endocrine and immune responses in a military patient cohort. A fundamental part of research is to feedback to patients, their relatives and ward staff on data collection and outcomes, and how future research may be improved to better support both injured SP and trauma patients in the UK. This paper will provide an experiential view on the delivery, operations and infrastructure requirements that should be considered when developing military research at a role-3 facility, before, during and after a study. Keywords: Open access PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/bmjmilitary-2020-001467 Issue No:Vol. 167, No. 2 (2021)
Authors:
Lamblin, A; Derkenne, C, Radavidson, A. Pages: 122 - 125 Abstract: The primary mission of the French military surgical teams deployed in external operations in the Sahel is to provide support for combatants. However, many of their activities and of the limited human and material resources allocated to them are devoted to providing free medical assistance to the local population. The French military surgical teams are very often expected to take care of serious burns for the benefit of civil populations because of the absence of dedicated civilian medical structures. Surgical teams are faced with a necessary triage of patients to be taken care of because of the discrepancy between the high demand for care and the means at their disposal. But the triage can lead to ethical dilemmas when the values that come into play in the decision contradict each other or when they run up against the quota of available human and material resources, as well as the interests of the military institution. The challenge is then to become aware of these dilemmas in this particular context. A discussion of these ethical dilemmas would help carers to avoid developing fatalistic attitudes or developing chronic pathologies due to unresolved or unconscious predicaments. Solutions are proposed that place ethical reflection at the heart of the practices during external operations by the French surgical teams. The ethics of discussion must bring together all players in care management and also the military authorities, before, during and after the missions. Training programmes for ethical reflection would benefit surgical teams and help them approach and become aware of the dilemmas they will necessarily face. PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/jramc-2019-001327 Issue No:Vol. 167, No. 2 (2021)
Authors:
Chapman, S; Rawcliffe, A. J, Smith, L, Izard, R, Roberts, J. Pages: 126 - 130 Abstract: IntroductionIt is important to collate the literature that has assessed dietary intake within military settings to establish which methods are commonly used and which are valid so that accurate nutrition recommendations can be made. This scoping review aims to identify which methods are typically used to assess dietary intake in military settings and which of these have been validated. This review also aims to provide a recommendation as to which method(s) should be used in military settings.MethodsThis scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Searches were conducted in PubMed, Web of Science and SPORTDiscus with the most recent search executed on 12th June 2020. Eligible studies had to report original data, assess and quantify dietary intake and have been published in peer-reviewed academic journals. The reporting bias was calculated for each study where possible.ResultsTwenty-eight studies used a single method to assess dietary intake and seven studies used a combination of methods. The most commonly used methods were the gold standard food intake/waste method, Food Frequency Questionnaire (FFQ) or a food diary (FD). The only method to date that has been validated in military settings is weighed food records (WFR).ConclusionsThe food intake/waste method or WFR should be used where feasible. Where this is not practical the FFQ or FD should be considered with control measures applied. There is currently not sufficient evidence to state that using multiple methods together improves validity. PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/bmjmilitary-2020-001436 Issue No:Vol. 167, No. 2 (2021)
Authors:
Fenn, B. P; Song, J, Casey, J, Waryasz, G. R, DiGiovanni, C. W, Lubberts, B, Guss, D. Pages: 131 - 136 Abstract: IntroductionMusculoskeletal foot and ankle injuries are commonly experienced by soldiers during military training. We performed a systematic review to assess epidemiological patterns of foot and ankle injuries occurring during military training.MethodsA review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search, done on 14 February 2019, resulted in 1603 reports on PubMed, 565 on Embase and 3 on the Cochrane Library. After reading the remaining full-text articles, we included 91 studies.ResultsAmong a population of 8 092 281 soldiers from 15 countries, 788 469 (9.74%) foot and ankle injuries were recorded. Among the 49 studies that reported on length of training, there were 36 770/295 040 (18.17%) injuries recorded among women and 248 660/1 501 672 (16.56%) injuries recorded among men over a pooled mean (±SD) training period of 4.51±2.34 months. Ankle injuries were roughly 7 times more common than foot injuries, and acute injuries were roughly 24 times more common than non-acute injuries. Our findings indicated that, during a 3-month training period, soldiers have a 3.14% chance of sustaining a foot and ankle injury. The incidence of foot or ankle injury during military parachutist training was 3.1 injuries per thousand jumps.ConclusionsOur findings provide an overview of epidemiological patterns of foot and ankle injuries during military training. These data can be used to compare incidence rates of foot and ankle injuries due to acute or non-acute mechanisms during training. Cost-effective methods of preventing acute ankle injuries and non-acute foot injuries are needed to address this problem. PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/bmjmilitary-2020-001591 Issue No:Vol. 167, No. 2 (2021)
Authors:
Robins, J. M. W; Thomson, S, Sheikh, A. Pages: 137 - 137 Abstract: Traumatic brain injury is the leading cause of death in conflict and early surgical intervention achieves better outcomes. The British Army surgical kit includes a Hudson Brace and bit and Gigli saw for decompression of the cranial cavity. Here we demonstrate the Hudson Brace technique for non-neurosurgeons. PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/bmjmilitary-2020-001546 Issue No:Vol. 167, No. 2 (2021)
Authors:
Herron, J. B. T; Hay David, A, Hodgetts, T. J. Pages: 142 - 143 PubDate: 2021-03-23T08:51:31-07:00 DOI: 10.1136/bmjmilitary-2020-001662 Issue No:Vol. 167, No. 2 (2021)
Hybrid journal (It can contain Open Access articles)
