The benefits of joining forces.

Sam Foster, Chief Nurse, Oxford University Hospitals, considers the benefits of having military teams to assist and bring a fresh perspective to NHS Trusts during the pandemic.

Shock Index as a Predictor of Massive Transfusion and Emergency Surgery on the Modern Battlefield.

BACKGROUND: Shock Index (SI) has been used to predict the need for massive transfusion (MT) and emergency surgical procedures (ESP) in civilian trauma. We hypothesize that SI can reliably identify combat trauma patients that will require MT and ESP when applied to the resource-constrained, combat environment. METHODS: A retrospective review was performed within the Department of Defense Trauma Registry (2008-2016). SI was calculated using heart rate and systolic blood pressure on arrival to the initial facility with surgical capabilities. A threshold value of 0.8 was used to stratify patients into two groups (Group I, SI < 0.8; and Group II, SI ≥ 0.8). The need for MT, ESP, and mortality was compared. Regression analyses were conducted to determine the independent association of SI with MT and ESP. RESULTS: A total of 4008 patients were included. The mean age of the patients was 25.5 y, and the majority were predominately male (98%). Mechanisms of injury were blunt and blast injury (62%), penetrating injury (36.7%), and burn injury (0.5%). Overall, 77% of patients (n = 3070) were stratified to Group I, and 23% of patients (n = 938) were stratified to Group II, by SI. Group II patients had a significantly greater need for MT (8.4% versus 0.4%) and ESP (30.7% versus 6.5%), both P < 0.001. Regression analysis controlling for age, gender, Injury Severity Score, and Glasgow Coma Score confirmed that SI ≥ 0.8 was an independent risk factor for both MT and need for ESPs (P < 0.001). CONCLUSIONS: SI is a significant predictor of the need for MT and ESPs in the military trauma population, representing a simple and potentially potent tool for triage and prediction of resource consumption in the resource-limited, austere setting.

Improving concussion education: consensus from the NCAA-Department of Defense Mind Matters Research & Education Grand Challenge.

Early disclosure of possible concussive symptoms has the potential to improve concussion-related clinical outcomes. The objective of the present consensus process was to provide useful and feasible recommendations for collegiate athletic departments and military service academy leaders about how to increase concussion symptom disclosure in their setting. Consensus was obtained using a modified Delphi process. Participants in the consensus process were grant awardees from the National Collegiate Athletic Association and Department of Defense Mind Matters Research & Education Grand Challenge and a multidisciplinary group of stakeholders from collegiate athletics and military service academies. The process included a combination of in-person meetings and anonymous online voting on iteratively modified recommendations for approaches to improve concussion symptom disclosure. Recommendations were rated in terms of their utility and feasibility in collegiate athletic and military service academy settings with a priori thresholds for retaining, discarding and revising statements. A total of 17 recommendations met thresholds for utility and feasibility and are grouped for discussion in five domains: (1) content of concussion education for athletes and military service academy cadets, (2) dissemination and implementation of concussion education for athletes and military service academy cadets, (3) other stakeholder concussion education, (4) team and unit-level processes and (5) organisational processes. Collectively, these recommendations provide a path forward for athletics departments and military service academies in terms of the behavioural health supports and institutional processes that are needed to increase early and honest disclosure of concussion symptoms and ultimately to improve clinical care outcomes.

Prevent, Detect, and Treat: The Military's Flexible Approach for a Whole-of-Nation Pandemic Response.

As community transmission of COVID-19 first emerged in the United States and then quickly spread, America's military accepted an important role in responding to the growing pandemic. The Department of Defense (DOD) rapidly mobilized and deployed personnel, expeditionary medical capabilities, supplies, and equipment to hot spots across the country. How does a military with an expeditionary focus and armed for war abroad quickly pivot to support national response efforts to a public health crisis here at home? Coinciding with the DOD's established flexible response methodology, the US Army adapted a three-pronged approach to prevent, detect, and treat COVID-19 while protecting the force and safeguarding the American people. This approach is providing strategic and operational lessons for improving healthcare delivery, informing public health decisions, and allocating healthcare resources for future pandemic response and civil emergency support efforts.

How do I get an emergency civilian walking blood bank running?

The shift toward using a transfusion strategy in a ratio to mimic whole blood (WB) functionality has revitalized WB as a viable option to replace severe blood loss in civilian health care. A military-civilian collaboration has contributed to the reintroduction of WB at Haukeland University Hospital in Bergen, Norway. WB has logistical and hemostatic advantages in both the pre- and in-hospital settings where the goal is a perfectly timed balanced transfusion strategy. In this paper, we describe an event leading to activation of our emergency WB collection strategy for the first time. We evaluate the feasibility of our civilian walking blood bank (WBB) to cover the need of a massive amount of blood in an emergency situation. The challenges are discussed in relation to the different stages of the event with the recommendations for improvement in practice. We conclude that the use of pre-screened donors as a WBB in a civilian setting is feasible. The WBB can provide platelet containing blood components for balanced blood resuscitation in a clinically relevant time frame.

Lifeline for the front lines: blood products to support the warfighter.

BACKGROUND: Hemorrhage is the leading cause of death on the battlefield. Damage control resuscitation guidelines in the US military recommend whole blood as the preferred resuscitation product. The Armed Services Blood Program (ASBP) has initiated low-titer group O whole blood (LTOWB) production and predeployment donor screening to make whole blood more available to military forces. STUDY DESIGN AND METHODS: ASBP donor centers updated procedures and labeling for LTOWB production. Donors are screened according to US Food and Drug Administration regulations and standard operating procedures. Group O donors are tested for anti-A and anti-B titer levels. Additionally, military personnel notified for pending deployment coordinate with their local ASBP donor center to complete whole blood donor prescreening. The process consists of completing a donor history questionnaire, processing of blood samples for blood group and infectious disease testing, and titer determination for group O personnel. RESULTS: Since March 2016, 7940 LTOWB units have been manufactured at ASBP donor centers and shipped in support of combat operations. Additionally, ASBP donor centers have screened several thousand service members before deployment. From these screenings, the donor low titer rate was 68% and infectious disease reactive test rate was extremely low (≤0.004). CONCLUSION: Whole blood is now the preferred blood product for resuscitation of combat trauma patients. The ASBP partnered with combat forces to screen personnel before deployment. Additionally, LTOWB is manufactured and shipped in support of combat operations. These efforts are expanding the availability of LTOWB for the warfighter.

Five years of prolonged field care: prehospital challenges during recent French military operations.

BACKGROUND: French military operations in the Sahel conducted since 2013 over more than 5 million square kilometers have challenged the French Military Health Service with specific problems in prolonged field care. STUDY DESIGN AND METHODS: To describe these challenges, we retrospectively analyzed the prehospital data from the first 5 years of these operations within a delimited area. RESULTS: One hundred eighty-three servicemen of different nationalities were evacuated, mainly as a result of explosions (73.2%) or gunshots (21.9%). Their mean number evacuation was 2.2 (minimum, 1; maximum, 8) per medical evacuation with a direct evacuation from the field to a Role 2 medical treatment facility (MTF) for 62% of them. For the highest-priority casualties (N = 46), the median time [interquartile range] from injury to a Role 2 MTF was 130 minutes [70 minutes to 252 minutes], exceeding 120 minutes in 57% of cases and 240 minutes in 26%. The most frequent out-of-hospital medical interventions were external hemostasis, airway and hemopneumothorax management, hypotensive resuscitation, analgesia, immobilization, and antibiotic administration. Prehospital transfusion (RBCs and/or lyophilized plasma) was started three times in the field, two times during helicopter medical evacuation, and five times in tactical fixed wing medical aircraft. Lyophilized plasma was confirmed to be particularly suitable in these settings. One of the specific issues involved in lengthy prehospital time was the importance to reassess and convert tourniquets prior to Role 2 MTF admission. CONCLUSION: Main challenges identified include reducing evacuation times as much as possible, preserving ground deployment of sufficiently trained medics and medical teams, optimization of transfusion strategies, and strengthening specific prolonged field care equipment and training.

Variations in prenatal screening in a US federal healthcare system: Same coverage, different options.

The Military Health System (MHS) is a federally funded organization that provides care to active duty service members and their beneficiaries. Our objective was to determine what methods of prenatal screening are used by military treatment facilities (MTFs), assess variations between institutions, and determine how practice patterns align with national recommendations. We surveyed all MTFs offering comprehensive prenatal care (n = 49). Departments were asked about aneuploidy screening options, availability of diagnostic testing, and carrier screening. In all, 43 MTFs (88%) completed the survey. Most (39/43) patients were stratified based on risk (predominantly maternal age at delivery and history). The most commonly offered test was combined 1st/2nd trimester screening (59%). Sixty percent routinely offered diagnostic testing, though less than half routinely offered microarrays. The majority offered universal carrier screening for cystic fibrosis (98%) and complete blood count with screening for thalassemias and hemoglobinopathies (88%). At the time of data collection, only five facilities (12%) had implemented spinal muscular atrophy carrier screening. Considerable heterogeneity exists in prenatal aneuploidy testing and carrier screening within the MHS. Standardized guidelines, protocols, and laboratory support would improve processes across the system. Additional resources including genetic counseling support and provider education are needed.

Military and industrial performance: the critical role of noise controls.

Noise control is a well understood and important engineering skill. The science has been developed to address operational needs of being quiet on the one hand, and avoiding hearing loss on the other, both in industry and military operations. Noise control is also the first priority step in systems safety risk mitigation for noise hazards, as evidenced in U.S. industry by the requirement stated in Federal OSHA regulation 1910.95: "(b)(1) When employees are subjected to sound exceeding those listed in Table G-16, feasible administrative or engineering controls shall be utilized." In actual practice, engineering controls are of first preference, while the second step is administrative noise controls, reducing noise exposures by removing personnel from high-noise environments. The third is the use of personal protective equipment (PPE), commonly known as earmuffs and earplugs. Each of these topics is discussed herein. The U.S. Navy has developed and/or implemented many groundbreaking noise control efforts on ships, and that provides the basis of discussion in this article. This article, as an overview of noise control, also addresses issues associated with high-noise environments and consideration of noise control techniques.

Marching on the Road to Quality: Army Public Health Experience Adopting NACCHO's Roadmap to a Culture of Quality Framework.

The US Army Public Health Center (APHC) adopted the National Association of County and City Health Officials' (NACCHO) Roadmap to a Culture of Quality (CoQ) Improvement framework to define its current culture and adapted the NACCHO's Organizational CoQ Self-Assessment Tool for applicability to a federal agency and workforce. More than 500 Civilian and Military personnel completed the self-assessment in October 2017. The results indicated that the APHC was categorized in the third of six total phases of the NACCHO's Roadmap to a CoQ (Phase 3: Informal or Ad Hoc QI Activities), which generated 13 transitional strategies to advance the APHC toward a CoQ. The APHC demonstrated that a federal public health organization can use and apply results from currently available self-assessment tools and frameworks related to a CoQ. By doing so, the APHC is optimizing its ability to ensure America's Soldiers and the Army Family receive essential and effective public health services.

[From corpsman to rescuer, the missed nurse's ideal towards the end of italian Risorgimento]. / Da portaferiti a soccorritore, l'ideale mancato di infermiere militare sul finir del Risorgimento italiano.

INTRODUCTION: Military corps have always been supported by healthcare providers who took care of the injured and sick soldiers. Traditionally the military nurse's figure has never been fully appreciated to the point that, even nowadays, it is still searching for its own identity. AIM: The aim of the study is to describe the military nurse's role from the Second War for Italian Independence (1859) to the conquest of Rome (1870). METHODS: Historical investigation. Secondary sources were consulted to carry out a geopolitical and historical contextualization of the reference period, while to trace the military nurse's evolution the team referred to primary sources. All the mentioned sources were analyzed according to Chabod's methodology (2012). RESULTS: The military nurse was born as a corpsman. The Risorgimento wars contributed to highlight the major contribution that nurses could give to military healthcare. In 1863 the Ministry of War elaborated a new and innovative profile for military nurses which foresaw particular physical and moral requirements, but also specific competences. Even though a new ideal of nurse was created, the Military Nurses Corp did not experience any changes: the nurses' activities remained transporting the injured and assisting doctors. CONCLUSIONS: Primary sources analysis highlighted an important attention towards the military nurse's role and education after national unity, although the gap shown by the military healthcare service during the Risorgimento battles was evident. Such condition facilitated the development of the first rescue committees which became, at a later time, the International Red Cross. The committees popularity allowed the volunteers to gain higher fame and social prestige than military nurses.

Effect of an equal-access military health system on racial disparities in colorectal cancer screening.

BACKGROUND: Racial disparities in colorectal cancer (CRC) screening are frequently attributed to variations in insurance status. The objective of this study was to ascertain whether universal insurance would lead to more equitable utilization of CRC screening for black patients in comparison with white patients. METHODS: Claims data from TRICARE (insurance coverage for active, reserve, and retired members of the US Armed Services and their dependents) for 2007-2010 were queried for adults aged 50 years in 2007, and they were followed forward in time for 4 years (ages, 50-53 years) to identify their first lower endoscopy and/or fecal occult blood test (FOBT). Variations in CRC screening were compared with descriptive statistics and multivariate logistic regression. RESULTS: Among the 24,944 patients studied, 69.2% were white, 20.3% were black, 4.9% were Asian, and 5.6% were other. Overall, 54.0% received any screening: 83.7% received endoscopy, and 16.3% received FOBT alone. Compared with whites, black patients had higher screening rates (56.5%) and had 20% higher risk-adjusted odds of being screened (95% confidence interval [CI], 1.11-1.29). Asian patients had a likelihood of screening similar to that of white patients (odds ratio [OR], 1.06; 95% CI, 0.92-1.23). Females (OR, 1.20; 95% CI, 1.10-1.33), active-duty personnel (OR, 1.15; 95% CI, 1.06-1.25), and officers (OR, 1.28; 95% CI, 1.18-1.37) were also more likely to be screened. CONCLUSION: Within an equal-access, universal health care system, black patients had higher rates of CRC screening in comparison with prior reports and even in comparison with white patients within the population. These findings highlight the need to understand and develop meaningful approaches for promoting more equitable access to preventative care. Moreover, equal-access, universal health insurance for both the military and civilian populations can be presumed to improve access for underserved minorities.

Proposed specifications of a mobile operating room for far-forward surgery

Summary: Provision of initial surgery to casualties within one hour of injury is associated with better survival. Where evacuation options are limited, surgery within the "golden hour" may have to occur close to the point of injury. Interventions close to the point of injury are limited by the adverse environment. Far-forward surgery has a long history going back to Dominique Larrey of the Napoleonic Army. We reviewed previous reports and used our own experience of far-forward surgery to describe the specifications of the ideal mobile operating room that would address some of these environmental barriers.

Utilization profile of the Canadian-led coalition Role 2 Medical Treatment Facility in Iraq: the growing requirement for multinational interoperability

Background: The Canadian Armed Forces deployed a Role 2 Medical Treatment Facility (R2MTF) to Iraq in November 2016 as part of Operation IMPACT. We compared the multinational interoperability required of this R2MTF with that of similar facilities previously deployed by Canada or other nations. Methods: We reviewed data (Nov. 4, 2016, to Oct. 3, 2017) from the electronic Disease and Injury Surveillance Report and the Daily Medical Situation Report. Clinical activity was stratified by Global Burden of Diseases category, ICD-10 code, mechanism of injury, services used, encounter type, nationality and blood product usage. We reviewed the literature to identify utilization profiles for other MTFs over the last 20 years. Results: In total, 1487 patients were assessed. Of these, 5.0% had battle injuries requiring damage-control resuscitation and/or damage-control surgery, with 55 casualties requiring medical evacuation after stabilization. Trauma and disease non-battle injuries accounted for 44% and 51% of patient encounters, respectively. Other than dental conditions, musculoskeletal disorders accounted for most presentations. Fifty-seven units of fresh frozen plasma and 64 units of packed red blood cells were used, and the walking blood bank was activated 7 times. Mass casualty activations involved coordination of health care and logistical resources from more than 12 countries. In addition to host nation military and civilian casualties, patients from 15 different countries were treated with similar frequency. Conclusion: The experience of the Canadian R2MTF in Iraq demonstrates the importance of multinational interoperability in providing cohesive medical care in coalition surgical facilities. Multinational interoperability derives from a unique relationship between higher medical command collaboration, international training and adherence to common standards for equipment and clinical practice.

Contexte: Les Forces armées canadiennes ont déployé une installation de traitement médical de rôle 2 (ITMR2) en Iraq en novembre 2016 dans le cadre de l'opération IMPACT. Nous avons comparé l'interopérabilité multinationale requise par cette ITMR2 à celle d'installations semblables déjà déployées par le Canada ou d'autres pays. Méthodes: Nous avons examiné les données (du 4 novembre 2016 au 3 octobre 2017) du rapport électronique de surveillance des maladies et des blessures et du rapport quotidien sur la situation médicale. L'activité clinique a été stratifiée selon la catégorie du fardeau mondial des maladies, le code de la CIM­10, le mécanisme de traumatisme, les services utilisés, le type de contact, la nationalité et l'utilisation de produits sanguins. Enfin, nous avons aussi examiné la littérature pour déterminer les profils d'utilisation d'autres ITM au cours des 20 dernières années. Résultats: Au total, 1487 patients ont été évalués. De ce nombre, 5,0 % avaient subi des blessures au combat qui nécessitaient une réanimation ou une intervention chirurgicale de contrôle des dommages, ou les deux, et 55 blessés avaient eu besoin d'évacuation médicale après stabilisation. Les traumatismes et les maladies non liées au combat représentaient respectivement 44 % et 51 % des contacts avec les patients. Outre les troubles dentaires, les troubles musculosquelettiques étaient à l'origine de la plupart des présentations. Par ailleurs, 57 unités de plasma frais congelé et 64 unités de concentré de globules rouges ont été utilisées, et la banque de sang ambulante a été activée 7 fois. La mobilisation nécessaire pour traiter un nombre massif de victimes a nécessité la coordination des soins de santé et des ressources logistiques de plus de 12 pays. En plus des victimes militaires et civiles du pays hôte, des patients de 15 pays différents ont été traités à une fréquence semblable. Conclusion: L'expérience de l'ITMR2 canadienne en Iraq démontre l'importance de l'interopérabilité multinationale quant à la prestation de soins médicaux cohérents dans les installations chirurgicales de la coalition. L'interopérabilité multinationale découle d'une relation unique s'appuyant sur la collaboration des membres du commandement médical supérieur, de la formation internationale et le respect de normes communes pour l'équipement et la médecine clinique.

Blood transfusion management in the severely bleeding military patient.

PURPOSE OF REVIEW: Hemorrhage remains the primary cause of preventable death on the battlefield and in civilian trauma. Hemorrhage control is multifactorial and starts with point-of-injury care. Surgical hemorrhage control and time from injury to surgery is paramount; however, interventions in the prehospital environment and perioperative period affect outcomes. The purpose of this review is to understand concepts and strategies for successful management of the bleeding military patient. Understanding the life-threatening nature of coagulopathy of trauma and implementing strategies aimed at full spectrum hemorrhage management from point of injury to postoperative care will result in improved outcomes in patients with life-threatening bleeding. RECENT FINDINGS: Timely and appropriate therapies impact survival. Blood product resuscitation for life-threatening hemorrhage should either be with whole blood or a component therapy strategy that recapitulates the functionality of whole blood. The US military has transfused over 10 000 units of whole blood since the beginning of the wars in Iraq and Afghanistan. The well recognized therapeutic benefits of whole blood have pushed this therapy far forward into prehospital care in both US and international military forces. Multiple hemostatic adjuncts are available that are likely beneficial to the bleeding military patient; and other products and techniques are under active investigation. SUMMARY: Lessons learned in the treatment of combat casualties will likely continue to have positive impact and influence and the management of hemorrhage in the civilian trauma setting.

Fentanyl lozenge story part 2: from military procurement to package.

This paper describes the selection of fentanyl as a replacement for morphine as the United Kingdom Ministry of Defence's first-line battlefield analgesic agent. It is a detailed review of the 6 year journey from selection to eventual roll-out in October 2017. It concentrates on the procurement and governance process of the deployment of fentanyl for individual issue and self-use. It highlights the significant differences in military and civilian legislation, the specialist environment we work in and the safety concerns surrounding controlled drugs in the austere environment. The lessons learnt can be applied to other organisations working in specialist environments that are looking to improve patient care through novel or off-license techniques that meet legislative resistance.

The Centre for Defence Healthcare Engagement: a focus for Defence Engagement by the Defence Medical Services.

The 2015 Strategic Defence and Security Review committed the government to an ambitious programme of Defence Engagement. This paper provides a short summary of the medical contribution to UK Defence Engagement. It then describes the intentions behind the creation of the Centre for Defence Health Engagement.

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.

Lessons from the organisation of the UK medical services deployed in support of Operation TELIC (Iraq) and Operation HERRICK (Afghanistan).

This paper provides the definitive record of the UK Defence Medical Services (DMS) lessons from the organisation of medical services in support of Operation (Op) TELIC (Iraq) and Op HERRICK (Afghanistan). The analysis involved a detailed review of the published academic literature, internal post-operational tour reports and post-tour interviews. The list of lessons was reviewed through three Military Judgement Panel cycles producing the single synthesis 'the golden thread' and eight 'silver bullets' as themes to institutionalise the learning to deliver the golden thread. One additional theme, mentoring indigenous healthcare systems and providers, emerged as a completely new capability requirement. The DMS has established a programme of work to implement these lessons.

Formation of Defence Primary Healthcare: a new way of delivering firm base primary healthcare.

Following the Strategic Defence and Security Review of 2010, the UK Surgeon General was directed to merge the delivery of primary healthcare from the three single Service organisations to a unified Defence Primary Healthcare. Although front line clinical staff were to be preserved, considerable savings were to be made in headquarters staff. This was one of the largest UK military medicine changes in delivery for a generation. The changes were completed on time with the transfer of UK and overseas general practice, specialist community services and dentistry, with a later requirement to add healthcare for the Reserves. The first years of this initiative have been remarkably successful, and Defence Primary Healthcare (DPHC) has progressively increased performance in all the QOF criteria measured by Defence Statistics.