The success of battlefield surgical airway insertion in severely injured military patients: a UK perspective.

BACKGROUND: The insertion of a surgical airway in the presence of severe airway compromise is an uncommon occurrence in everyday civilian practice. In conflict, the requirement for insertion of a surgical airway is more common. Recent military operations in Afghanistan resulted in large numbers of severely injured patients, and a significant proportion required definitive airway management through the insertion of a surgical airway. OBJECTIVE: To examine the procedural success and survival rate to discharge from a military hospital over an 8-year period. METHODS: A retrospective database and chart review was conducted, using the UK Joint Theatre Trauma Registry and the Central Health Records Library. Patients who underwent surgical airway insertion by UK medical personnel from 2006 to 2014 were included. Procedural success, demographics, Injury Severity Score, practitioner experience and patient survival data were collected. Descriptive statistics were used for data comparison, and statistical significance was defined as p<0.05. RESULTS: 86 patients met the inclusion criterion and were included in the final analysis. The mean patient age was 25 years, (SD 5), with a median ISS of 62.5 (IQR 42). 79 (92%) of all surgical airways were successfully inserted. 7 (8%) were either inserted incorrectly or failed to perform adequately. 80 (93%) of these procedures were performed either by combat medical technicians or General Duties Medical Officers (GDMOs) at the point of wounding or Role 1. 6 (7%) were performed by the Medical Emergency Response Team. 21 (24%) patients survived to hospital discharge. DISCUSSION: Surgical airways can be successfully performed in the most hostile of environments with high success rates by combat medical technicians and GDMOs. These results compare favourably with US military data published from the same conflict.

Challenging the dogma of traumatic cardiac arrest management: a military perspective.

Attempts to resuscitate patients in traumatic cardiac arrest (TCA) have, in the past, been viewed as futile. However, reported outcomes from TCA in the past five years, particularly from military series, are improving. The pathophysiology of TCA is different to medical causes of cardiac arrest, and therefore, treatment priorities may also need to be different. This article reviews recent literature describing the pathophysiology of TCA and describes how the military has challenged the assumption that outcome is universally poor in these patients.

The experience of Teesside helicopter emergency services: doctors do not prolong prehospital on-scene times.

BACKGROUND: The benefits of helicopter emergency medical services (HEMSs) attending the severely injured have been documented in the past. The benefits of doctors attending HEMS casualties have been demonstrated in particular in inner-urban and metropolitan areas. However, for UK regions with potentially less major trauma, concerns have been raised by ambulance services that a willingness of doctors to "stay and play" may lead to unnecessary delays on-scene without any additional benefit to the patient. AIMS: To identify factors that do prolong on-scene time, establish whether doctors "stay and play" on-scene compared with paramedics and document how often advanced medical skills may have to be used by HEMS doctors working outside the London HEMS environment. METHODS: Patient report form data were studied with regard to the number of and mean on-scene times of missions flown to (A) road-traffic collisions (RTCs), (B) other trauma calls (OTCs) and (C) medical emergencies. Trauma missions (categories A and B) were further subcategorised with regard to associated patient entrapment. Any advanced medical interventions (AMIs) performed by HEMS doctors were recorded and categorised. Finally, we looked at the difference in on-scene times for physician-paramedic partnerships (PPPs) and conventional paramedic crews (CPCs) for the above categories and subcategories. RESULTS: A total of 203 patient report forms were identified and examined. In all, 44.3% of missions were flown to RTCs with a further 44.3% for OTCs and 11.4% to medical emergencies. AMIs were performed by HEMS doctors in 34.1% of PPP missions, with a prehospital rapid sequence induction rate of 3.8%. Overall mean on-scene time was 25 min, with no difference for PPP and CPC missions. The mean on-scene time was prolonged by 6 min for RTCs (p = 0.006) and by 23 min for patient entrapment (p<0.001). No significant differences were found for the comparison between PPPs and CPCs in any of the subgroups A-C. However, there seemed to be a trend towards reduced on-scene times of PPPs for medical emergencies and patient entrapments. DISCUSSION: This study did not show any significant prolongation of mean on-scene times for PPP missions either overall or for any of the subgroups A-C. The fact that AMIs were performed in a large number of missions attended by HEMS doctors seems to further justify their current role in providing improved care at the roadside without leading to any delays in transfer to definitive care.

A double amino-acid change in the HLA-A peptide-binding groove is associated with response to psychotropic treatment in patients with schizophrenia.

The choice of an efficient psychotropic treatment for patients with schizophrenia is a key issue to improve prognosis and quality of life and to decrease the related burden and costs. As for other complex disorders, response to drugs in schizophrenia is highly heterogeneous and the underlying molecular mechanisms of this diversity are still poorly understood. In a carefully followed-up cohort of schizophrenic patients prospectively treated with risperidone or olanzapine, we used a specially designed single-nucleotide polymorphism (SNP) array to perform a large-scale genomic analysis and identify genetic variants associated with response to psychotropic drugs. We found significant associations between response to treatment defined by the reduction in psychotic symptomatology 42 days after the beginning of treatment and SNPs located in the chromosome 6, which houses the human leukocyte antigen (HLA). After imputation of the conventional HLA class I and class II alleles, as well as the amino-acid variants, we observed a striking association between a better response to treatment and a double amino-acid variant at positions 62 and 66 of the peptide-binding groove of the HLA-A molecule. These results support the current notion that schizophrenia may have immune-inflammatory underpinnings and may contribute to pave the way for personalized treatments in schizophrenia.