Justifying the implementation of intraoperative computed tomography for midface fracture treatment in improving outcomes.

Intraoperative CT scanning is the international standard for treating midface fractures as it allows intraoperative assessment of reduction and fixation. To our knowledge, no NHS hospital in the UK has this facility yet due to the financial and logistical burden of its implementation. The aim of this study was to determine if complications including the requirement for a return to theatre (RTT) could have been predicted from the post-fixation CT scan. All treated midface fractures that had presented to a regionalised major trauma centre within two years (01 January 2020 - 31 December 2021) were identified. Those developing complications including RTT were determined. All postoperative CT scans (including those without complication or RTT) were re-analysed with the clinicians blinded to the outcomes to determine the positive predictive value (PPV) and negative predictive value (NPV) of requiring RTT to alter plate position intraoperatively based on CT scan alone. In all, there were eight episodes of unplanned return to theatre, resulting in an overall RTT rate of 8/119 (6.7%). When only analysing patients treated for orbital fractures this RTT rises to 8/40 (20%). Of those eight patients who had a postoperative CT and required RTT, this could have been predicted in 7/8 (87.5%). A total of 16/44 (36.4%) patients that did not have RTT would have additionally been recommended to have the plate position altered based on CT alone. Based upon those that had a CT, the PPV of CT alone being able to predict those requiring RTT was 40.6% and the NPV 96.2%. Our results would suggest intraoperative CT would likely have prevented eight patients requiring RTT in two years and could have improved outcomes in 16 cases. In preventing RTT as well as potentially improving the outcomes of a further 16 cases in maxillofacial surgery, the purchase of an intraoperative CT scanner could yield net savings of £75534-£114990 over two years.

How should we manage severe anxiety towards dental treatment in UK service personnel?

Anxiety towards dental treatment is a significant barrier towards care within the United Kingdom Armed Forces. Avoidance of dental treatment results in morbidity, and severe dental infections can lead to systemic disease, which in turn may require hospitalisation. Of greater concern are deployed phobic patients who may develop dental pathology or suffer dental trauma and will likely require evacuation to the UK or a suitable host nation. This has considerable financial implications and in a war setting may place everyone in the evacuation chain at greater risk especially considering that it is not possible to manage these patients in Role 1 or 2 environments. Managing anxiety using either sedation or a general anaesthetic as a long-term management strategy for anxious military patients is simply not practical. This is reflected by current Defence policy stating that service personnel who are unable to tolerate treatment under local anaesthetic (LA) alone should be medically downgraded. However, the situation should ideally be addressed at the time of first recruitment. Currently, despite regulations recommending that potential new military recruits who cannot tolerate routine dentistry under LA should be medically discharged, in reality the subjectivity of such an assessment means this rarely happens. We would instead recommend that following identification of dental phobic recruits in initial training, they be placed in a holding platoon while methods to address their anxiety are explored. This would potentially avoid them entering military service and ultimately being discharged.

Non-surgical management of non-condylar mandibular fractures.

Unlike fractures of the remaining facial skeleton, fractures of the non-condylar part of the mandible are invariably treated surgically, with the potential risk of further iatrogenic injury. There is, however, a substantial evidence gap pertaining to the potential non-surgical management of such injuries. The aim of this study was to determine the outcomes of mandibular fractures treated with non-surgical management. All patients with mandibular fractures who were referred to a large regional major trauma service over a one-year period (1 January-31 December 2021) were identified. Those treated with surgery or who sustained fractures of the condylar portion of the mandible were excluded. Of all the patients referred to our unit with mandibular fractures, 34/155 (22%) underwent non-surgical management. In all cases plain radiographs demonstrated minimal displacement. Thirty-two (94%) fractures were unilateral, of which 24 (70%) involved the angle. Two of 34 patients subsequently required open reduction and internal fixation due to pain that did not improve over time, one of whom declined. A minimally extruded tooth in the fracture line, which altered the occlusion in one additional patient, required minimal reduction of the enamel. The remaining patients healed without complication six weeks after injury. Non- surgical management requires careful case selection and regular follow up, so is of value to only a small proportion of patients. Twenty-two per cent of all mandibular fractures were managed non-surgically at our unit in one year, with a 97% success rate, demonstrating the potential utility of this strategy in carefully selected cases.

Bioethics in humanitarian disaster relief operations: a military perspective.

The ethical dilemmas faced every day by military personnel working within the NHS will potentially be very different to ones that will be faced in the wake of a humanitarian disaster. Allied to this the potentially differing objectives from military personnel when compared with other healthcare workers in these scenarios and a conflict of ethics could arise.Within this paper, the fundamentals of this conflict will be explored and how working within the military framework can affect clinical decisions. This is a paper commissioned as a part of the humanitarian and disaster relief operations special issue of BMJ Military Health.

Physician assistant utilisation in the US Armed Forces: applicability to the UK Defence Medical Services.

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.

Following COVID-19 clinicians now overwhelmingly accept virtual clinics in Oral and Maxillofacial Surgery.

Virtual consultations and telemedicine have been an emerging trend in modern medicine, which has seen acceleration in uptake across a wide range of specialties as a result of the COVID-19 pandemic. Following on from previous work by the authors in 2019 examining clinician and patient appetite for virtual consultations in maxillofacial surgery, we sought to evaluate whether there had been a change in attitudes as a result of the pandemic. A clinician survey of the consultants at a large teaching hospital and prospective data collection of virtual consultation outcomes was carried out from the inception of UK government lockdown measures to tackle the pandemic. From 151 consultations, 149 (98.7%) successfully established a working diagnosis and treatment plan and/or concluded an episode of patient care, without the need to convert to a face-to-face encounter between clinician and patient. The total number of consultations (virtual or otherwise) was significantly lower than the same time period the preceding year however (1,223 compared with 465 consultations). All consultants surveyed felt the pandemic had altered their opinion of virtual clinics and their place in maxillofacial surgery but cited a number of issues. Further work is required to understand the driving forces behind staff attitudes and the long-term adoption of telemedicine within the specialty as services return to some sense of normalcy.

Extending existing recommended military casualty evacuation timelines will likely increase morbidity and mortality: a UK consensus statement.

INTRODUCTION: Future conflicts may have limited use of aviation-based prehospital emergency care for evacuation. This will increase the likelihood of extended evacuation timelines and an extended hold at a forward hospital care facility following the completion of damage control surgery or acute medical interventions. METHODS: A three-round Delphi Study was undertaken using a panel comprising 44 experts from the UK armed forces including clinicians, logisticians, medical planners and commanders. The panel was asked to consider the effect of an extended hold at Deployed Hospital Care (Forward) from the current 2-hour timeline to +4, +8, +12 and +24 hours on a broad range of clinical and logistical issues. Where 75% of respondents had the same opinion, consensus was accepted. Areas where consensus could not be achieved were used to identify future research priorities. RESULTS: Consensus was reached that increasing timelines would increase the personnel, logistics and equipment support required to provide clinical care. There is a tipping point with a prolonged hold over 8 hours, after which the greatest number of clinical concerns emerge. Additional specialties of surgeons other than general and orthopaedic surgeons will likely be required with holds over 24 hours, and robust telemedicine would not negate this requirement. CONCLUSIONS: Retaining acute medical emergencies at 4 hours, and head injuries was considered a particular risk. This could potentially be mitigated by an increased forward capacity of some elements of medical care and availability of a CT scanner and intracranial pressure monitoring at over 12 hours. Any efforts to mitigate the effects of prolonged timelines will come at the expense of an increased logistical burden and a reduction in mobility. Ultimately the true effect of prolonged timelines can only be answered by close audit and analysis of clinical outcomes during future operations with an extended hold.

The ballistic performance of bone when impacted by fragments.

Physical models are required to generate the underlying algorithms that populate computer simulations of the effects of explosive fragmenting devices. These models and simulations are used for understanding weapon performance, designing buildings and optimising personal protective equipment. Previous experimental work has investigated the performance of skin and muscle when subjected to fragmentation threats, but limited evidence exists for the performance of bone when impacted by fragments. In the current work, ballistic testing was conducted using two types of internationally recognised steel fragment simulating projectiles (FSPs): (i) 5.5 mm diameter (0.68 g) ball bearing (BBs) and (ii) 1.10 g chisel nosed (CN). These projectiles were fired at isolated swine ribs at impact velocities between 99 and 1265 m/s. Impact events were recorded using a high-speed camera. Selected specimens were analysed post-impact with plain x-radiographs and micro-CT scanning to determine damage to the bone architecture. Bones were perforated with a kinetic energy density (KED) as low as 0.14 J/mm2. Energy transfer to the bone was greater for the CN FSPs, resulting in increased bone damage and the production of secondary bone fragments. The manner in which the bones failed with faster velocity impacts (> 551 m/s; KED > 6.44 J/mm2) was analogous to the behaviour of a brittle material. Slower velocity impacts (< 323 m/s; KED < 1.49 J/mm2) showed a transition in failure mode with the bone displaying the properties of an elastic, plastic and brittle material at various points during the impact. The study gives critical insight into how bone behaves under these circumstances.

Defining the medical coverage of ballistic protection to the pelvis and thigh.

INTRODUCTION: Pelvis, lower limb and associated genital injury caused by explosive devices was responsible for mortality and considerable long-term morbidity for the UK Armed Forces during combat operations in Afghanistan, resulting in the issue of a pelvic protection system in 2010. The aim of this current research was to determine the medical coverage of the pelvis and thigh and to define the vertical dimensions of ballistic protective material for future pelvic protection (PP). METHOD: CT scans from 120 male UK Armed Forces personnel were analysed to identify the anthropometric landmarks and vertical boundaries of coverage for the pelvis and thigh. Pelvic height was the vertical distance between the upper border of the iliac crest in the midaxillary plane to the most inferior point of the ischial tuberosity of the pelvis. Upper thigh height was proposed as a 100 mm fixed distance below the ischial tuberosities, enabling a tourniquet to be reproducibly applied. These distances were compared with the ballistic component of the five sizes of tier 1 PP using a paired t-test. RESULTS: The vertical components of coverage measured using CT scans were all significantly less (p<0.01) compared with all five sizes of tier 1 PP; for example, the ballistic component of the smallest size of tier 1 PP measured 410 mm, which was larger than the 99th percentile male, which measured 346 mm on CT scans. CONCLUSIONS: While all sizes of tier 1 PP provide coverage to the pelvis and upper thigh structures, there is an opportunity to optimise future PP. For example, comparing the large size of tier 1 PP to the 50th percentile male demonstrated an opportunity to reduce the ballistic protective component by 31%. Reducing the quantity of material used will improve heat dissipation and user comfort and reduce material mass and acquisition costs.

Clinicians' and patients' acceptance of the virtual clinic concept in maxillofacial surgery: a departmental survey.

Virtual clinics have been proposed as a method of reducing costs and improving services in the National Health Service (NHS). The aim of this research was to assess the attitudes of clinicians and patients towards virtual consultations in a department of oral and maxillofacial surgery (OMFS). Patients and clinicians at conventional OMFS adult outpatient clinics were prospectively interviewed using a structured questionnaire. Variables recorded included type of consultation, overall attitude, time travelled, and mode of transport. Patients' notes were assessed retrospectively to check if examinations had been done. A total of 146 patients (100%) completed the surveys, and 108 of them (74%) were amenable to having virtual consultations in the future. Such appointments may have been suitable for 19 patients who did not have examinations. Chi squared analysis showed no relation between type of appointment and preference for a virtual consultation (p=0.087). To introduce a virtual consultation system in our department and to assess its efficacy once implemented, further development and research are required.

Nerve agents: emergency preparedness.

Nerve agents (NAs) are a highly toxic group of chemical warfare agents. NAs are organophosphorus esters with varying physical and chemical properties depending on the individual agent. The most recently developed class of NA is ' Novichok ', the existence of which was first revealed in the early 1990s, just before Russia signed the Chemical Weapons Convention. In 1984, Iraq became the first nation to deploy NA on the battlefield when they used tabun against Iranian military forces in Majnoon Island near Basra. The first terrorist use of an NA is believed to be the attack in Matsumoto, Japan, on 27 June 1994 by the Aum Shinrikyo doomsday cult. Symptoms and ultimate toxicity from NA poisoning are related to the agent involved, the form and degree of exposure, and rapidity of medical treatment. The classic toxidrome of significant exposure to NA comprises bronchorrhoea, bronchospasm, bradycardia and convulsions, with an onset period of as early as a few seconds depending on the mode and extent of exposure. If medical management is not instituted rapidly, death may occur in minutes by asphyxiation and cardiac arrest. In the UK, emergency preparedness for NA poisoning includes an initial operational response programme across all blue light emergency services and key first responders. This paper describes the development, pathophysiology, clinical effects and current guidance for management of suspected NA poisoning. It also summarises the known events in which NA poisoning has been confirmed.

Minimum depths to essential structures in a UK military population using computed tomography: application to stab-resistant body armour.

INTRODUCTION: Edged weapons are a known domestic threat to the police forces of the UK. This threat is mitigated by wearing stab-resistant body armour that is either worn overtly or covertly depending on role. Although the UK military have traditionally focused their body armour design upon ballistic and fragmentation threats, future roles may require protection against an edged weapon threat. Since 2017, UK police body armour requirements for anatomical coverage for both edged weapon and ballistic threats are now based upon the requirements of UK military. This revised coverage may need additional research to determine minimum distances to essential structures. METHOD: Three entry locations and penetration vectors were chosen using the limited available information in the literature, in combination with a specialist in edged weapons defence. One hundred twenty CT trauma scans of male military service personnel were subsequently analysed to ascertain minimum distances from skin surface to the first structure encountered that is included in essential coverage (heart, aorta, vena cava, liver and spleen) at 3 specific entry points. RESULTS: Individuals ranged between 18 and 46 years, with a mean body mass index of 24.8. The absolute minimum depth from skin surface to a structure within the auspice of essential coverage was 17 mm to the liver in entry point 3 and 19 mm to the heart in entry point 2. CONCLUSIONS: Minimum distances to critical structures were significantly larger than those described in previous studies on civilians. This study will be used to supplement existing evidence to support existing UK police requirements for stab-resistant body armour. Using the weapon entry sites and vectors described in this study, overmatching to a behind armour depth of 17 mm would cover all of this population in this study.

Developing a craniomaxillofacial and cervical equipment module for surgeons in the austere environment: a systematic review.

The treatment of craniomaxillofacial and cervical wounds in a disaster relief setting is done by clinicians from local medical treatment facilities, non-governmental organisations (NGO), or the military. Although each group and individual surgeon will need specific equipment, this will be restricted by weight, portability and interoperability. We systematically reviewed scientific and commercial publications according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The papers we identified described the portable equipment that is required to treat patients who need damage-control surgery (decompressive craniectomy, temporary stabilisation, and internal and external fixation of the facial bones) for craniomaxillofacial and cervical injuries in austere or military settings. Austere settings are those in which there is an inherent lack of infrastructure, such as facilities, roads, and power. A total of 35 papers or scientific articles recommended the equipment that is needed to manage these injuries, but we could find no module that was specifically designed for use in these environments. Multiple modules are currently required to provide comprehensive surgical care and many of the items in the existing maxillofacial and neurosurgical kits are rarely used, which increases the cost of initial procurement and resupply. Duplications in equipment between modules also increase the size, weight, and financial cost. We suggest the equipment that is required to make up a rationalised, lightweight, and compact module that can be used for all craniomaxillofacial and cervical operations in austere settings.

Noise-induced hearing loss in the military dental setting: a UK legislative perspective.

INTRODUCTION: Health professionals working in the dental environment are potentially at risk of noise-induced hearing loss (NIHL) due to the use of clinical and laboratory equipment. Workplaces engaging in the practice of dentistry within the UK are subject to legislation from the Control of Noise at Work (CNW) regulations 2005. Clinicians working in the military are at further increased risk of NIHL due to exposure from additional risk factors such as rifles or aircraft engines. To our knowledge, no authors have previously studied the noise levels experienced in a military dental setting or compared noise levels in a typical dental practice with current UK legislation. METHOD: Measurements of noise levels experienced by a dentist, dental nurse and dental hygienist during a standard conservation procedure were assessed using wearable noise dose-badges. Furthermore, noise levels within a dental technician's work space were also assessed. Noise levels produced by representative clinical and laboratory equipment were assessed and compared with CNW legislation. RESULTS: The highest level for clinical equipment was produced by the suction apparatus while aspirating up a cup of water at 76 dB. For laboratory equipment, the lower exposure action value (LEAV) of 80 dB would be exceeded in 2.1 hours' use of the trimmer, 3.6 hours' use of the vibrating table and 9 min use of the airline. CONCLUSIONS: Noise levels experienced by clinicians within the dental surgery were well below the legislative LEAV thresholds for both peak and continuous noise. However, noise levels produced by laboratory equipment were far higher and there is clearly the potential for excessive noise exposure for dental professional in the everyday setting. Dental professionals responsible for dental laboratory settings must be familiar with the CNW regulations and measures put in place that control the inadvertent breach of legislation. Hearing protection must be mandated when using equipment that exceeds the LEAV and an educational programme is required to explain both their correct use and the rationale behind it. Methods of mitigating that risk further require exploration such as alternative methods of completing the tasks performed by the airline or reducing the noise generated by it, such as by reducing the supply pressure or using an alternative nozzle design.

Operation RUMAN and the Ministry of Defence response to Hurricane Irma.

Operation RUMAN was the British government's combined military and humanitarian operations in September 2017 to provide relief to the British Overseas Territories in the Caribbean affected by Hurricane Irma. The Ministry of Defence (MoD), in conjunction with the Department for International Development, produced a tangible effect by the delivery of healthcare and a response to a humanitarian disaster with very little time for planning. The rescue element was accomplished within days but this was followed swiftly by a recovery phase requiring a 'whole force approach', with additional assets from non-governmental organisations and the private sector. The aim of this article is to provide information on the role of the Defence Medical Services on behalf of the MoD, and other departmental organisations in achieving the mission of providing medical and logistical support for these British Overseas Territories.