Dietary supplements and military operations: caution is advised.

We describe the case of a 32-year-old soldier who presented with acute organic psychosis during an operational tour to Iraq. This was precipitated by excessive consumption of caffeine coupled with additional use of oral nutritional stimulants. Her biochemical profile was compounded by the additional use of exogenous creatine. We present a brief overview of the issue of exercise supplementation and highlight some of the potential problems and clinical issues surrounding their use. This has important implications for both serving soldiers and the wider medical community.

Chemical, biological and radiation casualties: critical care considerations.

A chemical, biological, radiological or nuclear (CBRN) event would require a critical care response from point of exposure to definitive hospital management. Critical care staff should be aware of the potential agents and possible hazard they present to responders. The treatment of CBRN casualties should reflect the conventional incident and casualty management paradigms with additional safety and treatment considerations. Specific agents may require specific airway and respiratory considerations including surrogate ventilation strategies. All critical care staff training should include CBRN awareness and personal protective equipment training. Some staff may benefit from additional training including the recognition and investigation of CBRN casualties as well as their treatment and the equipment available. Critical care departments should also contingency plans for CBRN events including surge capacity.

Military perspective on the civilian response to the London bombings July 2005.

With the break up of the Warsaw Pact and changing global relations, current military deployments are becoming smaller and more expeditionary (e.g. Afghanistan, East Timor and Sierra Leone). During the Cold War, the use of weapons of mass effect was highly likely to have been seen on the battlefield. Ironically, the proliferation of CBRN agents and the knowledge of their application, as well as the manufacture of improvised explosive devices, have lead to the targeting of civilian populations by extremist groups. One of the benefits of military clinicians embedded in NHS hospital trusts, as well as a strong reservist cadre, is a greater understanding of the implications and management of asymmetric attacks against the U.K. The experience and skills of military clinicians may be of benefit to NHS trusts while this type of threat exists. Military clinicians are also likely to benefit from the experience that they get in certain NHS posts that provide skills that are readily transferable to military medicine. The events of 7th July highlighted the dynamic use of deployable medical resources and a rapid return to normal service provision. This type of 'Health Resilience' can only be achieved with a combination of effective emergency planning, on scene clinical risk management and clinical leadership.

Clinical toxicology and military application.

The changing operational tempo and types of deployment have, since the end of the Cold War, required a change in CBRN training. The threat from weapons of mass destruction has been replaced with the threat from improvised explosive devices and insurgent attempts to develop asymmetric weapons to target military and civilian populations. In addition exposure to hazardous materials as well as environmental hazards and natural toxins requires a greater awareness of the necessary supportive and definitive management. Developing a cadre of specialists with an interest in toxicology and environmental medicine, within either emergency or acute medicine, would be advantageous to deployed units as well as specialised units, including those tasked in support of UK homeland security. An established pathway for sub-specialisation in clinical toxicology does not yet exist. With the establishment of the College of Emergency Medicine, as well as the Acute Medicine Society and Intensive Care Society further development of clinical toxicology is likely.

HEMS training and the 7th July 2005: a personal perspective.

Since the 7th July, the Civil Contingencies Act 2004 has now come into force. Emergency services are required to have plans in place to response to a range of major incidents. The role of pre-hospital physicians has been recognised for sometime and was highlighted during the inquiry by Hidden QC into the 1988 Clapham rail disaster. The medical response from both HEMS and London BASICS was extraordinary on the day due to the significant number of clinicians attending the clinical governance day. The three post 7/7 reports have made several recommendations, the main recommendations focusing on communications and the management of uninjured survivors and relatives. None of the reports were completely independent, apolitical or peer reviewed, but they do provide useful information for emergency planners and responders. The problem with the absence of peer review is that situations can be interpreted as either half empty or half full. The scrutiny committee of the London Assembly suggested that the time taken to clear the scenes (approximately 3 hours) was too long. Previous experience of 'one-under' incidents has shown that a single casualty trapped under a train can take up to 90 minutes to be safety extricated. The management of over 700 casualties with a 50% conveyance rate to hospital at four incident sites within the documented timeframe was an achievement, but it is important not to be complacent. After a major incident many responders are left with a feeling of frustration and sometimes anger. The frustration is often due to the limitations a major incident places on clinical practice. Senior clinicians may be required to assume non-clinical roles and this is outside their comfort zone. Psychological effects on first responders are not easily quantifiable but support mechanisms should be in place and offered. Some people remember certain details while others may have difficulty recollecting events. I found my role frustrating, as did many, but also rewarding. It was something I would not want to go though again and I still don't remember the faces of many of the responders or casualties while I know that others do. One of the most important factors during the response and the recovery phase was team spirit. On scene all responders from all services were cooperating and supportive of each other. Afterwards, there was an opportunity to unwind with colleagues and this was extremely beneficial. This form of debrief has been seen after operational deployments and critical incidents. On reflecting on the day's events it was a privilege to work with the teams responding to the event of that day. The training, planning and response proved that the team works.

Management of the irradiated casualty.

The initial management of any irradiated casualty is the early identification of the possibility of a significant exposure through dose prediction and recognition of prodromal symptoms. Subsequent management is aimed at supporting the effected systems until there is recovery. Where there is haematological failure, transplantation (bone marrow / stem cell) is possible although limited value in a mass casualty scenario. The provision of gold standard therapy within the field is unlikely to occur and early medical evacuation to an Echelon / Role 4 facility with specialist services will be required. Within the field, early assessment using the above systems of classification could be achieved at Echelon / Role 3 and may be enhanced with the establishment of Radiation Assessment Units. These would select casualties that could benefit from the advanced therapies. A summary of the levels of care is shown in Figure 3.

Mass casualty management for radiological and nuclear incidents.

The decisions required for the provision of an appropriate medical response to a radiological or nuclear incident range from the traditional major incident response through to a compromised response due to a catastrophic event. A summary of the most likely clinical findings in the first 12-24 hours is given in Table 4. From these findings, appropriate management based upon the needs and available resources can be planned. This includes triage for surgery and the use of the expectant (T4) triage category.

The submarine service of the future?

Space missions, although now routine, are unique in terms of their environment and logistical requirements. The number of missions (man-hours) remains relatively small and planning still relies on comparisons with analogous missions, including submarine operations. Antarctic missions, which tend not to be classified, have provided more information about isolated communities because of the number of personnel per base. Space medicine has traditionally been an extension of aviation medicine with high g-forces involved in the transition from Earth to orbit and astronauts such as Neil Armstrong recruited from the test pilot fraternity. As the length of a mission increases and the space habitation relies more on regenerative systems, the environment becomes more analogous with today's nuclear submarines. As well as the air purification implications, radiation still is a significant hazard with even greater impact on future Mars missions requiring the provision of health physics monitoring, advice and countermeasures well established in the submarine flotilla. Nevertheless, the specialty space medicine will progress as a specialty in its own right, pooling expertise from other specialties such as aviation, radiation, emergency and occupational medicine taking human exploration beyond the confines of land and sea.

Mefanamic acid blood and urine levels in the horse determined by derivative gas-liquid chromatography-electron capture.

Mefenamic acid is extracted from biological fluids and is acylated with pentafluoropropionic anhydride to form a derivative possessing high electron affinity. The derivative is analyzed by gas-liquid chromatography with an electron capture detector. The method is particularly valuable for determining drug levels in blood where small sample and/or drug concentrations are available.