Fellowships and defence engagement: from clinical niches to strategic impact

Medical fellowships have traditionally developed the individual rather than furthering military or national strategic objectives. This paper describes a medical fellowship with the British Antarctic Survey to illustrate the benefits to the individual, to the military and to wider international defence engagement efforts.By rebranding such fellowships as Defence Healthcare Engagement and by treating international organisations on a par with partner nations, the humble fellowship can facilitate enduring, mutually beneficial healthcare engagement at low cost and with minimal additional resources.

War and disaster are forcing a major rethink around mass casualty management

Mass casualty events (MASCAL) do not follow the same rules as typical major incidents. In the West at least, the latter often occur in stable, networked trauma systems, whereas MASCAL are characterised by overwhelming numbers of patients, compounded by protracted scene and transport times, decompensated response systems and significant disruption to infrastructure, command and control.This paper describes the 8Ds approach being taken by the UK Defence Medical Services and the North Atlantic Treaty Organization Emergency Medicine Panel framework to approach MASCAL. The eight domains were derived from literature about management of casualties in the World Wars, and also from approaches taken by civilian health systems as they struggle to manage increasing demand. They are: distribute; decompress; delay; delegate; deliver faster and deliver better; dynamic levels of care; and de-escalate These domains will allow a structured approach to research and innovate around MASCAL, informing better guidelines for their management.

Military and Civilian Trauma System Integration: A Global Case Series

INTRODUCTION

Traumatic injury is a leading cause of morbidity globally, particularly in low-income and middle-income countries (LMICs). In high-income countries (HICs), it is well documented that military and civilian integration can positively impact trauma care in both healthcare systems, but it is unknown if this synergy could benefit LMICs. This case series examines the variety of integration between the civilian and military systems of various countries and international partnerships to elucidate if there are commonalities in facilitators and barriers.

METHODS

A convenience sampling method was utilized to identify subject matter experts on civilian and military trauma system integration. Data were collected and coded through an iterative process, focusing on the historical impetuses and subsequent outcomes of civilian and military trauma care collaboration.

RESULTS

Eight total case studies were completed, five addressing specific countries and three addressing international partnerships. Themes which emerged as drivers for integration included history of conflict, geography, and skill maintenance for military physicians. High-level government support was a central theme for successful integration, and financial issues were often seen as the greatest barrier.

CONCLUSIONS

Various approaches in civilian-military integration exist throughout the world, and the studied nations and international partnerships demonstrated similar motivators and barriers to integration. This study highlights the need for further investigation, particularly in LMICs, where less is known about integration strategies.

Comparison between Defence Healthcare Engagement and humanitarian assistance

Humanitarian assistance and Defence Healthcare Engagement have traditionally both been taught on the Medical Humanitarian Stabilisation Operations Course. However, the two activities are distinct. This paper outlines the critical differences between them, focusing on their specific purposes, scope, timescales and ethics. Humanitarian assistance will remain a distinct activity with a focus on the relief of suffering, guided by international norms, while Defence Healthcare Engagement will encompass a broader range of activities, less constrained by internationally agreed principles. This presents an opportunity for the Defence Medical Services to directly contribute to projecting UK influence, preventing conflict and building stability. However, it requires the Defence Medical Services to take responsibility for the ethical issues that Defence Healthcare Engagement raises. This paper recommends the development of an ethical framework that reconciles the strategic aims of Defence Healthcare Engagement with maximising patient welfare at the tactical level. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

Prehospital emergency care in a humanitarian environment: an overview of the ethical considerations

Recent history has demonstrated that UK Defence personnel can be used, potentially with little notice, in humanitarian disaster zones. The provision of prehospital emergency care (PHEC) in a humanitarian environment requires an innovative approach to overcome the technical challenges of a resource-limited setting. In addition to technical challenges, prehospital practitioners working in a humanitarian environment can expect to be faced with ethically testing situations that they are not familiar with in their usual practice. The organisational and individual ethical decision-making burden can result in significant harms. Therefore, the aim of this paper is to discuss the ethical considerations relevant to providing PHEC during a humanitarian disaster in order that personnel can be more prepared to optimally deliver care. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

Understanding medical civil-military relationships within the humanitarian-development-peace 'triple nexus': a typology to enable effective discourse

The interface between humanitarianism, development and peacebuilding is increasingly congested. Western foreign policies have shifted towards pro-active stabilisation agendae and so Civil-Military Relationships (CMRel) will inevitably be more frequent. Debate is hampered by lack of a common language or clear, mutually understood operational contexts to define such relationships. Often it may be easier to simply assume that military co-operation attempts are solely to 'win hearts and minds', rather than attempt to navigate the morass of different acronyms. In healthcare, such relationships are common and more complex - partly as health is seen as both an easy entry point for diplomacy and so is a priority for militaries, and because health is so critical to apolitical humanitarian responses. This paper identifies the characteristics of commonly described kinds of CMRel, and then derives a typology that describe them in functional groups as they apply to healthcare-related contexts (although it is likely to be far more widely applicable). Three broad classifications are described, and then mapped against 6 axes; the underlying military and civilian motivations, the level of the engagement (strategic to tactical), the relative stability of the geographical area, and finally the alignment between the civilian and military interests. A visual representation shows where different types may co-exist, and where they are likely to be more problematic. The model predicts two key areas where friction is likely; tactical interactions in highly unstable areas and in lower threat areas where independent military activity may undermine ongoing civilian programmes. The former is well described, supporting the typology. The latter is not and represents an ideal area for future study. In short, we describe an in-depth typology mapping the Civil-Military space in humanitarian and development contexts with a focus on healthcare, defining operational spaces and the identifying of areas of synergy and friction.

Prospective Surveillance of Respiratory Infections in British Antarctic Survey Bases During the COVID-19 Pandemic

BACKGROUND

The British Antarctic bases offer a semiclosed environment for assessing the transmission and persistence of seasonal respiratory viruses.

METHODS

Weekly swabbing was performed for respiratory pathogen surveillance (including SARS-CoV-2), at 2 British Antarctic Survey bases, during 2020: King Edward Point (KEP, 30 June to 29 September, 9 participants, 124 swabs) and Rothera (9 May to 6 June, 27 participants, 127 swabs). Symptom questionnaires were collected for any newly symptomatic cases that presented during this weekly swabbing period.

RESULTS

At KEP, swabs tested positive for non-SARS-CoV-2 seasonal coronavirus (2), adenovirus (1), parainfluenza 3 (1), and respiratory syncytial virus B (1). At Rothera, swabs tested positive for non-SARS-CoV-2 seasonal coronavirus (3), adenovirus (2), parainfluenza 4 (1), and human metapneumovirus (1). All bacterial agents identified were considered to be colonizers and not pathogenic.

CONCLUSIONS

At KEP, the timeline indicated that the parainfluenza 3 and adenovirus infections could have been linked to some of the symptomatic cases that presented. For the other viruses, the only other possible sources were the visiting ship crew members. At Rothera, the single symptomatic case presented too early for this to be linked to the subsequent viral detections, and the only other possible source could have been a single nonparticipating staff member.

Time trends in adrenaline auto-injector dispensing patterns using Australian Pharmaceutical Benefits Scheme data

AIM

Adrenaline auto-injector (AAI) dispensing data, a community-based proxy for number of individuals at risk of anaphylaxis, provides complementary information on time trends of anaphylaxis risk in addition to hospital admission data. We examined trends of AAI dispensing over a 10-year period (from January 2005 to December 2014) in Australia.

METHODS

Individuals with dispensed AAI were identified from a 10% random sample of Australian Pharmaceutical Benefits Scheme (PBS) data. PBS is the Australian national drug subsidy programme covering all Australians. Cumulative incidence and incidence rates of individuals with AAI were calculated. We assessed difference by age, sex, state and time trends.

RESULTS

The cumulative incidence of individuals with AAI in 2005-2014 was 75.43/100 000 (95%CI 75.07-75.80/100 000). Incidence rate of individuals with AAI increased from 2005 to 2014 (from 71.47 to 82.07 per 100 000 person-years) although this varied by state. Over the time assessed, there was a shift to more prescriptions being provided by general practitioners (GP) rather than specialists. Children (0-19 years) were more likely to have been prescribed an AAI from a specialist and adults from a GP.

CONCLUSION

Overall, an increase in dispensed AAI mirrored other evidence for a rising prevalence of allergy. This increase could also reflect changes in prescribing practices or increased awareness and education of health-care professionals on anaphylaxis and indications for prescribing AAI. The rising rate of AAI prescribed by GPs compared to decreasing rates by specialists suggests a changing response of the Australian health-care system to the increased burden of anaphylaxis.

49 The Effective Management of Resources in a Busy Sim Centre

The efficient working of a busy, multi-faceted Healthcare Simulation Centre that caters to many different stakeholders requires a repertoire of protocols and procedures. Standard Operating Procedures (SOPs) ensure all resources are managed as effectively as they can be so that teaching can be continuously delivered at the optimum level.

The aim of this wide-ranging project was to devise a collection of SOPs and accompanying files that regulate the efficient management of resources in a Sim Centre.

A template for SOPs was created, with entries for background, purpose, scope, procedures etc. ensuring each SOP would meet a universal standard for the department. They also must be approved by the Simulation Manager and reviewed annually. Accompanying documents, spreadsheets and online forms to facilitate that the processes outlined in the SOPs would also have to be created.

The SOPs include maintenance and servicing of equipment, loaning of equipment, booking of equipment for teaching and self-directed practise, inventory, management of Simulation spaces and storage areas, stock-taking and ordering of consumables. A suite of instructional documents, data management spreadsheets and online forms have been prepared and are updated regularly in accordance with the procedures outlined in the SOPs. Much of what simulation staff do is learned on the job and losing that institutional knowledge can be devastating for a program. To combat this the SOPs capture the essential steps to efficiently run our centre. The SOPs are useful tools to communicate the correct way of carrying out an activity and are used to orientate and train new technical staff in our centre. Importantly, the SOPs are an integral part of our quality enhancement process, updated regularly, and used to communicate innovations and improvements amongst the wider centre user community. These SOPs and associated resources will be made available to the simulation community upon request.

Personal view: security sector health systems and global health

In many countries the security sector is a major contributor to the healthcare system. The role and transformation of a state’s security health system within the universal health coverage is important, in that it sits at the interface of the United Nations Sustainable Development Goals 3 (ensure healthy lives and promote well-being) and 16 (promote just, peaceful and inclusive societies). The paper describes the breadth of the security sector and outlines the potential beneficiaries, clinical services and macro-organisation of a security sector health system from the perspective of its contribution to wider government health services and crisis response. It examines the characteristics of the security sector compared with other providers of health services, including those generic to the sector and unique to a given service. Understanding civil–security relationships is a critical facet of effective Defence Healthcare Engagement (DHE), which includes the use of defence medical assets in support of capacity-building overseas. The analytical process described may form the basis of DHE planning. It may have even greater importance in the near future as countries review national resilience and global health diplomacy after the COVID-19 crisis.

UK Defence Medical Services’ support to the development of a multiagency major incident plan in South Sudan

UK Defence Medical Services personnel deployed in support of the United Nations Mission in South Sudan as part of Operation TRENTON in 2017–2018. One key contribution was the development of a multiagency major incident plan in collaboration with key stakeholders within the region, including our UN partners, other troop-contributing countries and non-governmental organisations. This paper describes the process and contribution made, with some transferable lessons for future similar operations, such as adaptation of our courses. Major incident management is one of several technical areas ripe for a proactive Defence Healthcare Engagement strategy, seeking to offer capacity building in areas where Defence is rich in expertise that is highly sought after by other sectors.

Dry Rehydratable Film Method for Enumerating Confirmed Escherichia coli in Poultry, Meats, and Seafood: Collaborative Study

A rehydratable dry-film plating method for Escherichia coli, the Petrifilm E. coli/Coliform (EC) Count Plate in foods, has been compared with the AOAC INTERNATIONAL most probable number (MPN) method. Eleven laboratories participated in the collaborative study. Three E. coli levels in 8 samples each of frozen raw ground turkey, frozen raw ground beef, and frozen cooked fish were tested in duplicate. Mean log counts for the Petri film plate procedure were not significantly different from those for the MPN procedure for cooked fish samples inoculated with low or high inocula levels, for samples of raw turkey inoculated at medium level, and for beef inoculated at low, medium, and high levels. Repeatability and reproducibility vari ances of the Petrifilm EC Plate method recorded at 24 h were as good as or better than those of the MPN method. The dry rehydratable film method for enumerating confirmed E. coli in poultry, meats, and seafood has been adopted first action by AOAC INTERNATIONAL.

Medical civil–military interactions on United Nations missions: lessons from South Sudan

This paper outlines the United Nations’ integrated response to complex humanitarian emergencies and the different types of interactions that may occur between militaries and civilian organisations involved in them. It uses a recent UK deployment to South Sudan as an example, drawing on the experience to highlight areas of particular interest to healthcare workers. It identifies several domains that should usefully be developed for both civilians and military personnel in these environments—including sharing our expertise in major incident management, proof-of-concept testing for novel diagnostic and treatment solutions and offering to engage in joint continuing medical education. These gaps in organisational policy should be addressed and appropriate training pathways designed to maximise the contribution of the Defence Medical Services in similar contexts in the future.

Changes in NHS Major Incident management and their relevance to the Defence Medical Services

High-profile Major Incidents in the UK civilian setting in the last few years have appropriately raised awareness of the principles and frameworks involved in the design of reliable response systems. The introduction of the Joint Emergency Services Interoperability Principles in tandem with increased investment in Major Incident Planning has supported practitioners to successfully respond to high numbers of incidents.

Defence Medical Services personnel are increasingly being asked to deploy to resource-limited 'contingency' settings where much of the established guidance relating to Major Incident response requires reconsideration and modification in the face of severely constrained space, manpower and equipment.

This editorial seeks to review contemporary theories and principles of Major Incident response and discuss how military medical personnel may need to adapt these to address the various Major Incident challenges that they may face on operations.

Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone

BACKGROUND

Limited data exist describing supportive care management, laboratory abnormalities and outcomes in patients with Ebola virus disease (EVD) in West Africa. We report data which constitute the first description of the provision of enhanced EVD case management protocols in a West African setting.

METHODS

Demographic, clinical and laboratory data were collected by retrospective review of clinical and laboratory records of patients with confirmed EVD admitted between 5 November 2014 and 30 June 2015.

RESULTS

A total of 44 EVD patients were admitted (median age 37 years (range 17-63), 32/44 healthcare workers), and excluding those evacuated, the case fatality rate was 49% (95% CI 33%-65%). No pregnant women were admitted. At admission 9/44 had stage 1 disease (fever and constitutional symptoms only), 12/44 had stage 2 disease (presence of diarrhoea and/or vomiting) and 23/44 had stage 3 disease (presence of diarrhoea and/or vomiting with organ failure), with case fatality rates of 11% (95% CI 1%-58%), 27% (95% CI 6%-61%), and 70% (95% CI 47%-87%) respectively (p = 0.009). Haemorrhage occurred in 17/41 (41%) patients. The majority (21/40) of patients had hypokalaemia with hyperkalaemia occurring in 12/40 patients. Acute kidney injury (AKI) occurred in 20/40 patients, with 14/20 (70%, 95% CI 46%-88%) dying, compared to 5/20 (25%, 95% CI 9%-49%) dying who did not have AKI (p = 0.01). Ebola virus (EBOV) PCR cycle threshold value at baseline was mean 20.3 (SD 4.3) in fatal cases and 24.8 (SD 5.5) in survivors (p = 0.007). Mean national early warning score (NEWS) at admission was 5.5 (SD 4.4) in fatal cases and 3.0 (SD 1.9) in survivors (p = 0.02). Central venous catheters were placed in 37/41 patients and intravenous fluid administered to 40/41 patients (median duration of 5 days). Faecal management systems were inserted in 21/41 patients, urinary catheters placed in 27/41 and blood component therapy administered to 20/41 patients.

CONCLUSIONS

EVD is commonly associated life-threatening electrolyte imbalance and organ dysfunction. We believe that the enhanced levels of protocolized care, scale and range of medical interventions we report, offer a blueprint for the future management of EVD in resource-limited settings.

Triage and the Modified Physiological Triage Tool-24 (MPTT-24)

Major incidents occur on a regular basis. So far in 2017, England has witnessed five terrorism-related major incidents, resulting in approximately 40 fatalities and 400 injured. Triage is a key principle in the effective management of a major incident and involves prioritising patients on the basis of their clinical acuity. This paper describes the limitations associated with existing methods of primary major incident triage and the process of developing a new and improved triage tool-the Modified Physiological Triage Tool-24 (MPTT-24). Whilst the MPTT-24 is likely to be the optimum physiological method for primary major incident triage, it needs to be accompanied by an appropriate secondary triage process. The existing UK military and civilian secondary triage tool, the Triage Sort, is described, which offers little advantage over primary methods for identifying patients who require life-saving intervention. Further research is required to identify the optimum method of secondary triage.

An outbreak inside an epidemic: managing an infectious disease outbreak while treating Ebola

Even in the middle of an epidemic of a very serious illness, outbreaks of other infectious diseases will continue. Clinicians need to be able to make rapid decisions about the nature of the outbreak and how to manage it. A balance needs to be struck between managing all patients as if they have the worst-case scenario illness and the resultant risks to themselves, their colleagues and the mission. This paper reviews basic epidemiological tools that inform robust decision-making in the management of such outbreaks. It then describes how a pragmatic approach, combined with effective use of these techniques, rapid diagnostics and remote specialist support, allowed a large outbreak of gastroenteritis to be safely and effectively managed during the response to the Ebola virus disease epidemic in Sierra Leone.

Coordination and relationships between organisations during the civil-military international response against Ebola in Sierra Leone: an observational discussion

The Ebola virus disease (EVD) crisis in West Africa began in March 2014. At the beginning of the outbreak, no one could have predicted just how far-reaching its effects would be. The EVD epidemic proved to be a unique and unusual humanitarian and public health crisis. It caused worldwide fear that impeded the rapid response required to contain it early. The situation in Sierra Leone (SL) forced the formation of a unique series of civil-military interagency relationships to be formed in order to halt the epidemic. Civil-military cooperation in humanitarian situations is not unique to this crisis; however, the slow response, the unusual nature of the battle itself and the uncertainty of the framework required to fight this deadly virus created a situation that forced civilian and military organisations to form distinct, cooperative relationships. The unique nature of the Ebola virus necessitated a steering away from normal civil-military relationships and standard pillar responses. National and international non-governmental organisations (NGOs), Department for International Development (DFID) and the SL and UK militaries were required to disable this deadly virus (as of 7 November 2015, SL was declared EVD free). This paper draws on personal experiences and preliminary distillation of information gathered in formal interviews. It discusses some of the interesting features of the interagency relationships, particularly between the military, the UK's DFID, international organisations, NGOs and departments of the SL government. The focus is on how these relationships were key to achieving a coordinated solution to EVD in SL both on the ground and within the larger organisational structure. It also discusses how these relationships needed to rapidly evolve and change along with the epidemiological curve.

Op GRITROCK ethics; the way of things to come?

The Defence Medical Services (DMS) deployed on Op GRITROCK to Sierra Leone in support of the Ebola outbreak. This operation was the first large-scale DMS deployment since operations in Afghanistan ceased at the end of 2014. This type of operation revealed a number of ethical issues and challenges that the DMS had not faced for a long time. The ethical issues identified during the deployment are discussed in this article using the principalism approach of Beauchamp and Childress. Many of these issues were not identified prior to deployment, and troops were not adequately prepared. The article will outline the difficulties of using the principles of autonomy, beneficence, non-maleficence and justice during a public health emergency, and conclude with recommendations for ethical considerations that should be identified and mitigated against for future deployments to a public health emergency.

A Health Care Worker with Ebola Virus Disease and Adverse Prognostic Factors Treated in Sierra Leone

We describe the management of a Sierra Leonean health care worker with severe Ebola virus disease complicated by diarrhea, significant electrolyte disturbances, and falciparum malaria coinfection. With additional resources and staffing, high quality care can be provided to patients with Ebola infection and adverse prognostic factors in west Africa.

Preparation of the trauma response in a UK emergency department

An immediate, effective team response is needed in order to properly cater to the needs of trauma patients. This paper aims to review some of the strategies that can be implemented in Emergency Departments to reduce errors and improve decision-making in major trauma. It focuses on the phase prior to the patient’s arrival, and in the first few minutes afterwards – as there is evidence that an organised response at this point creates the ideal conditions for all subsequent activity, such as transfer of the patient for further imaging and the requirement for emergency surgery.

UK Triage the validation of a new tool to counter an evolving threat

INTRODUCTION

Major Incidents (MI) occur frequently and their unpredictable nature makes prospective research difficult and largely unethical. A key step in MI management is triage; the identification of the critically injured. Within a MI environment this is commonly performed using simple physiological ‘tools’, such as the Triage Sieve (TS). However the most commonly used tools appear to lack an evidence base. In a previous study, the authors used a military population to compare the performance of the TS to the Military Sieve (MS) at predicting need for Life-Saving Intervention (LSI). The MS differs only with the addition of a measurement of consciousness. The outcome from this study was that the MS outperformed the TS, but could be further improved with small changes to its physiological parameters, the Modified Military Sieve (MMS).

MATERIALS AND METHODS

Physiological data and interventions performed within the Emergency Department (ED) and Operating Theatre were prospectively collected for consecutive adult trauma patients (>18years) presenting to the ED at Camp Bastion, Afghanistan between March and September 2011. All patients receiving a LSI were considered Gold Standard Priority One. Patients were triaged using the TS, MS, MMS, START (ST) and Careflight (CF) triage tools. Sensitivities and specificities were estimated with 95% confidence intervals and differences were checked for statistical significance using a McNemar test with Bonferroni correction.

RESULTS

482 patients presented to the ED during the study period, sufficient data was recorded for 335 (71%) with 199 (59%) P1s. The MMS (sensitivity 68.3%, specificity 79.4%) showed an absolute increase in sensitivity over existing tools ranging from 5.0% (MS) to 23.6% (CF). There was a statistically significant difference (P = 0.0005) between the MMS and MS.

DISCUSSION

A key limitation to this study, is the use of a military cohort to validate the MMS, a tool which itself was developed using military data. The mechanism of injury also is unlikely to translate fully to the civilian population.

CONCLUSIONS

Within a military population, the MMS outperforms existing MI triage tools. Before it is recommended as a replacement to the existing TS in UK civilian practice, it needs to be tested in a civilian environment.

Intraosseous access in the military operational setting

INTRODUCTION

In an operational military environment, circulatory access can prove difficult for a variety of reasons including profound hypovolaemia, and limited first responder experience. With many injuries that cause catastrophic haemorrhage, such as traumatic limb amputations, circulatory access is needed as quickly as possible. Since 2006, the Defence Medical Services have been using the EZ-IO and FAST1 devices as a means of obtaining circulatory access.

METHODS

A prospective observational study was conducted between March and July 2011 at the Emergency Department, Camp Bastion, Afghanistan. All patients with an intraosseous device had data recorded that included if the device successfully flushed (functionality) and if any problems were encountered.

RESULTS

117 patients presented with a total of 195 devices: 149 were EZ-IO (76%) and 46 were FAST1 (24%). Functionality was recorded for 111 (57%), with 17 failing to function, yielding an overall success rate of 84.7%. Device failure was observed to be more prevalent in the humerus; inability to flush the device was the leading cause, followed by mechanical failure. There were 2 complications, device breaking on removal being the reason for both.

CONCLUSIONS

The devices in the study were tested for a period of time following insertion (median 32 minutes), and still the success rates mirror those found in the literature. Observed differences between sites were not found to be significant with confidence intervals overlapping. Further work is proposed to investigate the long-term complications of intraosseous devices.

UK triage--an improved tool for an evolving threat

INTRODUCTION

A key challenge at a major incident is to quickly identify those casualties most urgently needing treatment in order to survive - triage. The UK Triage Sieve (TS) advocated by the Major Incident Medical Management (MIMMS) Course categorises casualties by ability to walk, respiratory rate (RR) and heart rate (HR) or capillary refill time. The military version (MS) includes assessment of consciousness. We tested whether the MS better predicts need for life-saving intervention in a military trauma population. Ideal HR, RR and Glasgow Coma Score (GCS) thresholds were calculated.

METHODS

A gold standard Priority 1 casualty was defined using resource-based criteria. Pre-hospital data from a military trauma database allowed calculation of triage category, which was compared with this standard, and presented as 2×2 tables. Sensitivity and specificity of each physiological parameter was calculated over a range of values to identify the ideal cut-offs.

RESULTS

A gold standard could be ascribed in 1657 cases. In 1213 both the MS and TS could ascribe a category. MS was significantly more sensitive than TS (59% vs 53%, p<0.001) with similar specificity (89 vs 88%). Varying the limits for each parameter allowed some improvements in sensitivity (70-80%) but specificity dropped rapidly.

DISCUSSION

Previous studies support the inclusion of GCS assessment for blunt as well as penetrating trauma. Optimising the physiological cut-offs increased sensitivity in this sample to only 71% - a Sieve based purely on physiological parameters may not be capable of an acceptable level of sensitivity.

CONCLUSIONS

The MS is more sensitive than the TS. Major incident planners utilising the Sieve should consider adopting the military version as their first line triage tool. If validated, altering the HR and RR thresholds may further improve the tool.

Psoas abscess secondary to haematoma after a fall causing multiple osteoporotic fractures

A 78-year-old woman presented 28 days after a low-impact fall, where she sustained a right pubic ramus fracture, with increasing left hip pain and fever. Her blood results showed a high white cell count and deranged urea and electrolytes. An MRI revealed multiple osteoporotic fractures and bilateral gluteal abscesses with left iliopsoas abscess, which had likely formed in a haematoma of a sacral fracture. She received a long course of intravenous antibiotics and CT-guided drainage of the abscesses. She developed symptoms of cauda equina, but no evidence of epidural extension of the abscess was found at operation. She required neurorehabilitation. This case highlights the complications of pelvic osteoporotic fractures, and high associated morbidity and mortality in the elderly population.

Ultrasound of penetrating ocular injury in a combat environment

Penetrating eye injuries are uncommon in a civilian environment, but unfortunately, very common in a military emergency department. Ultrasound of the eye is quick, reliable, accurate, and easy to learn. This review aims to demonstrate normal anatomy and penetrating injuries of the anterior and posterior compartments of the eye.

Preparation of the resuscitation room and patient reception

Experience from the Role 3 Medical Treatment Facility in Afghanistan has allowed the development of a variety of processes to improve management of seriously injured patients. This review describes some of the techniques that facilitate the reception of the patient in the Emergency Department. In particular the preparation of the team and the resuscitation bay, and the way the team members work together to optimise assessment and resuscitation while minimising delay to imaging and surgery. Within this context the systems described have been refined and function effectively. Many of these lessons may be relevant to future deployments.

Critical decision-making and timelines in the emergency department

The resuscitation of severely injured patients has evolved during the last decade. Patients are now surviving injuries that previously were thought to be unsurvivable. Systems have been put in place, that reflect the intensity of workload and severity of injury of patients presenting to deployed medical treatment facilities. This paper aims to describe some of the elements that may differ from routine practice in the resuscitation room, and in particular the role of timelines in the management of such patients.

Solid-State Characterization of Buspirone Hydrochloride Polymorphs

The purpose of this study was to characterize Form 1 and Form 2 of buspirone hydrochloride, an anxiolytic medicine. The techniques used for characterization included microscopy (optical, hot stage, and scanning electron microscopy), thermal analysis (differential scanning calorimetry and thermogravimetric analysis), solid-state Fourier transform infrared (FTIR) spectroscopy, X-ray powder diffractometry (XRPD), and Raman spectroscopy. Morphologically, Form 1 and Form 2 consist of plate and columnar crystals, respectively, with good filterability. Thermal analysis showed that the two forms are enantiotropic over the studied temperature range. The FTIR method was used successfully for the quantification of Form 1 in a mixture of Forms 1 and 2. The ratio of a characteristic peak to a reference peak and the chemometric method were used to obtain the calibration curve. The Raman peak shifts showed the difference between the two forms especially for the n-butyl group. The large number of distinguishable XRPD peaks in the region of 5 degrees to 30 degrees 2theta of the two polymorphs demonstrated that XRPD is a useful tool for quantitative and qualitative analysis of polymorphs.

Burnout in direct care staff in intellectual disability services: a factor analytic study of the Maslach Burnout Inventory

BACKGROUND

There is gathering research interest in the well-being of staff working in services for people with intellectual disability (ID), including the assessment of burnout and its correlates. However, no previous studies have considered the applicability of the main three dimensions of burnout to staff in ID services.

METHODS

Data were analysed from two samples of staff (total n=184) who participated in research studies that included completion of the Maslach Burnout Inventory (MBI).

RESULTS

Nineteen of the MBI items loaded clearly onto factors closely resembling the three original subscales: emotional exhaustion, depersonalization and personal accomplishment. Internal consistency for the three MBI subscales was fair to good (range 0.68-0.87).

CONCLUSIONS

The original three MBI dimensions were found to be highly relevant to the present sample of staff. The analyses support the construct validity and reliability of the MBI for staff in ID services.

Phenomenology: understanding the life experience of long-term ventilated adolescents

To care effectively for young people requires insight into how the children think about their care and how they want to live their lives. A phenomenological approach was used to gain new understandings into the thoughts and experiences of two teenage boys who were on long-term ventilation. The method included use of dialogue, observation and a reflective diary. Five themes emerged which helped the team caring for the boys to plan and prioritise care. Phenomenology is recommended as one way for nurses to become more thoughtfully aware of their practice.

Domestic violence in Russia

Reported incidence and frequency rates of domestic violence in Russia exceed Western figures by 4 or 5 times. Although a grassroots social services movement has emerged to provide services for victims and families, a number of historical and cultural influences unique to Russia present challenges with regard to the problem of domestic violence. These include a history of institutional oppression of women, arcane legal procedures, a shortage of housing and shelters, untrained medical professionals, and widespread misinformation and myths about domestic violence. This article documents incidence and prevalence of domestic violence, cultural and historical influences, legal issues, and specific challenges to ending domestic violence in Russia.