Multinational medical support to operations: challenges, benefits and recommendations for the future.

This paper considers the strategic aspects of medical support to military operations as delivered through multi-national collaboration. The military medical services are in essence a people organisation; the purpose of the organisation is primarily to support the people engaged in military operations, and also the people providing healthcare to them. Increasingly, supporting the latter also includes preparation for the ethical dilemmas that they will face. Providing health advice and healthcare on operations is now usually undertaken on a multinational basis, in order to generate sufficient medical capacity to meet the requirement with assets of the appropriate (and NATO mandated) capability. This will be an enduring feature, particularly in light of increasing costs of providing high quality healthcare and the operational and logistic challenges of delivering this capability in adverse environments, and in the context of medical personnel being a limited resource. The key to overcoming the challenges, often the result of the "people issues" such as cultural differences, is to recognise the value that the inherent diversity of multinational healthcare provision brings. The benefit is realised through sharing best practice, and the lessons from challenges met, as well as through burden sharing, and to understand that challenges are most commonly the result of misunderstandings, such as those inherent in language differences. The advice for those bringing a multinational team together includes considering the implications of culture (noting differences in national and military perspectives, and in medical processes such as clinical governance), to ensure effective communication, and to utilise feedback to confirm understanding. It is important not to prejudge or denigrate others. Share information and knowledge, provide positive reinforcement when things go well, and recognise that there will inevitably be challenges and use these as an opportunity to learn. Above all, the personal touch builds a culture within the multinational team that transcends national culture; celebrating success breeds success and thus optimal outcome for patients.

Audit of the effectiveness of command and control arrangements for medical evacuation of seriously ill or injured casualties in southern Afghanistan 2007.

AIMS: The effectiveness of the command and control of medical evacuation by helicopter (MEDEVAC) of casualties sustained in southern Afghanistan each month from 1 May to 31 July 2007 was audited. In this period 762 casualties of all categories were evacuated to International Security Assistance Force (ISAF) field hospital facilities under the direction of Operations and medical staff of NATO Regional Command (South) (RC-S). The criterion for the audit was the time taken from notification in the RC-S Combined Joint Operations Centre (CJOC) until the helicopter landed ("Wheels Down") at the destination field hospital's helicopter landing site. The standard to be met was 90 minutes for all "9-liner" Category A (URGENT) and Category B (URGENT - surgical) cases (in hospital within 2 hours of wounding) allowing for time from injury to first notification in the CJOC, and time from landing to transfer to the Emergency Department (30 minutes together) at the designated destination hospital. Those that did not meet this target were assessed in order to review their outcome and to identify means for improving performance. RESULTS: Analysis of evacuation times for all missions each month from May to July revealed that three quarters of A and B category missions met the 90 minute target. No adverse outcome resulted from those which did not meet this target, reasons for which included distance (more than 30 minutes flying time each way), delay in securing a hostile landing site, delay in obtaining sufficient information, incorrect categorization of the casualty's priority, and on one occasion, an overmatch of assets available at that time. No casualties died who were recoverable. Comparison with data from the two previous RC-S rotations (prior to 1 May 07) showed an improvement in mean response time, but little change in median response on the rotation of RC-S staff on 1 May 07. The major change that had occurred on this rotation was to move the medical operations staff into the CJOC. The convergence of median and mean at this time indicates a reduction in "outliers", providing evidence that collocation of medical and operations staff improves incident response and should be the "default setting" in deployed tactical formation headquarters. CONCLUSION: Regular audit of MEDEVAC response should be routine for Medical Operations staff, in order to ensure the optimal casualty care pathway from point of wounding to field hospital.

Training injuries--how clinicians can help commanders avoid them.

The aim of this paper is to reflect on the proceedings of three training injuries symposia run by the British Army's training organization from 2001 to 2003. The essence of the presentations are reproduced, highlighting the role of medical staff in advising commanders on how injuries might be prevented. The importance of placing the emphasis on prevention rather than rehabilitation as a means of reducing the impact of training injuries is first examined. Pre-employment medical selection standards, the design of training courses, nutrition, smoking, training injuries among women, heat injury and the psycho-social environment are then all reviewed. Finally, the outcome of workshop discussion groups are presented as practical guidance for medical officers and other clinicians, advising commanders on how training injuries amongst their personnel might be minimised.

Symposium--commemoration of the liberation of the Bergen-Belsen Concentration Camp and medical management of disasters study period.

Over the period 15/16 April 1998 a commemorative dinner and study period was held to recognise the role of the medical services in the management of the victims of the Bergen-Belsen Concentration Camp. Having been presented with a framework for planning medical support to these situations, one of the London medical students at Belsen in 1945 related his own experience at this unprecedented and horrific scene. Following this, the lessons that may be drawn were examined, the key factor being the need to create order out of chaos. The system used by the military for analysing what has to be achieved in a given situation, and the deductions that can be made from the prevailing factors, called the Estimate Process, emerged as a model for planning the medical contribution to disaster relief.

Humanitarian aid operations in Republica Srpska during Operation Resolute 2.

The humanitarian aid experience of a unit in Bosnia is described. Data are presented for primary care clinics undertaken, showing the range of conditions and age of patients seen. The role of the civilian aid agencies involved is described, together with recommendations for future training requirements for similar operations.