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Thompson M, Jefferson O, James T, Waller B, Reed R, Slade H, Swift K, Pynn HJ. Defining capabilities in deployed UK military prehospital emergency care. BMJ Mil Health 2024; 170:150-154. [PMID: 38508774 DOI: 10.1136/military-2022-002159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022]
Abstract
The UK military prehospital emergency care (PHEC) operational clinical capability framework must be updated in order that it retains its use as a valid operational planning tool. Specific requirements include accurately defining the PHEC levels and the 'Medical Emergency Response Team' (MERT), while reinforcing PHEC as a specialist area of clinical practice that requires an assured set of competencies at all levels and mandatory clinical currency for vocational providers.A military PHEC review panel was convened by the Defence Consultant Advisor (DCA) for PHEC. Each PHEC level was reviewed and all issues which had, or could have arisen from the existing framework were discussed until agreement between the six members of this panel was established.An updated military PHEC framework has been produced by DCA PHEC, which defines the minimum requirements for each operational PHEC level. These definitions cover all PHEC providers, irrespective of professional background. The mandatory requirement for appropriate clinical exposure for vocational and specialist providers is emphasised. An updated definition of MERT has been agreed.This update provides clarity to the continually evolving domain of UK military PHEC. It sets out the PHEC provider requirements in order to be considered operationally deployable in a PHEC role. There are implications for training, manning and recruitment to meet these requirements, but the processes required to address these are already underway and well described elsewhere.
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Affiliation(s)
- Michael Thompson
- Royal Air Force Medical Services, RAF High Wycombe, UK
- Emergency Department, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - O Jefferson
- Royal Air Force Medical Services, RAF High Wycombe, UK
- Emergency Department, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - T James
- Royal Air Force Medical Services, RAF High Wycombe, UK
- Emergency Department, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - B Waller
- Navy Command Headquarters, Navy Healthcare, Portsmouth, UK
- Shackleton Department of Anaesthetics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R Reed
- Joint Hospital Group South West, Defence Medical Services, Plymouth, UK
- Anaesthetic Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - H Slade
- Royal Air Force Medical Services, RAF High Wycombe, UK
- Emergency Department, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - K Swift
- Tactical Medical Wing, Royal Air Force Medical Services, RAF Brize Norton, UK
| | - H J Pynn
- Department of Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK
- Emergency Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Muller KL, Facciolla CA, Monti J, Cronin A. Impact of Succinct Training on Open Cricothyrotomy Performance: A Randomized, Prospective, Observational Study of U.S. Army First Responders. Mil Med 2020; 185:e1779-e1786. [PMID: 32567654 DOI: 10.1093/milmed/usaa035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/30/2019] [Accepted: 02/09/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Primary airway failure has become the second most common cause of potentially survivable battlefield fatality. Cricothyrotomy is taught to all U.S. military providers as a means of securing an airway in extremis. However, retrospective studies show that cricothyrotomy failure rates for U.S. military first responders performing the procedure in combat is 33%. Our hypothesis was that these rates could be improved. MATERIALS AND METHODS We conducted a randomized, prospective, observational study to evaluate the effects of inexpensive, succinct training on open cricothyrotomy performance by studying two unique U.S. Army First Responder participant groups. One participant group consisted of regular U.S. Army Medics (68 Ws). The second group was Special Operations Combat Medics. We evaluated both groups' baseline ability to correctly perform a cricothyrotomy and then randomly assigned individuals within each group to either a training or practice group. RESULTS The training group had a higher proportion of success and performed the cricothyrotomy faster than the practice group with 68 Ws group appearing to benefit most from training: their procedural success rates increased by an average of 23%, and their average time-to-correct-placement decreased by 21 seconds-a 33% improvement over baseline. CONCLUSION With one manikin, a qualified trainer, and $35 worth of expendable supplies, 10 medics could be trained in the procedure in just 2-3 hours. Our study suggests that this simple intervention has the potential to significantly improve U.S. Army First Responders' ability to correctly perform an open cricothyrotomy and drastically decrease the time needed to perform this lifesaving procedure correctly, possibly saving one in four potentially survivable combat casualties suffering from airway compromise.
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Affiliation(s)
- Kurtis L Muller
- Special Warfare Medical Group (Airborne) 1975 Combat Medic Rd, Fort Bragg NC 28310
| | | | - Jonathan Monti
- Madigan Army Medical Center 9040A Jackson Ave, Joint Base Lewis-McChord, WA 98431
| | - Aaron Cronin
- Madigan Army Medical Center 9040A Jackson Ave, Joint Base Lewis-McChord, WA 98431
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Travers S, Carfantan C, Luft A, Aigle L, Pasquier P, Martinaud C, Renard A, Dubourg O, Derkenne C, Kedzierewicz R, Franchin M, Bay C, Cap AP, Ausset S. Five years of prolonged field care: prehospital challenges during recent French military operations. Transfusion 2019; 59:1459-1466. [PMID: 30980759 DOI: 10.1111/trf.15262] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 01/18/2019] [Accepted: 01/18/2019] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Stéphane Travers
- 2ème Centre Médical des Armées, 12ème Antenne Médicale, French Military Health Service, Villacoublay, France.,French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France
| | - Cyril Carfantan
- French Military Health Service - Operational Headquarters, Paris, France
| | - Antoine Luft
- French Military Health Service - Operational Headquarters, Paris, France
| | - Luc Aigle
- French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France.,10ème Centre Médical des Armées, 154ème Antenne Médicale, French Military Health Service, Aubagne, France
| | - Pierre Pasquier
- French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France.,French Military Health Service, Percy Military Hospital, Clamart, France
| | - Christophe Martinaud
- French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France.,Centre de Transfusion Sanguine des Armées, French Military Health Service, Clamart, France
| | - Aurelien Renard
- Emergency Department, Saint Anne Military Hospital, French Military Health Service, Toulon, France
| | - Olivier Dubourg
- CMIA Saint-Denis, Antenne Médicale de St Pierre, French Military Health Service, La Réunion, France
| | - Clement Derkenne
- Paris Fire Brigade Medical Emergency Department, French Military Health Service, Paris, France
| | - Romain Kedzierewicz
- Paris Fire Brigade Medical Emergency Department, French Military Health Service, Paris, France
| | - Marilyn Franchin
- 2ème Centre Médical des Armées, 12ème Antenne Médicale, French Military Health Service, Villacoublay, France
| | - Christian Bay
- French Military Health Service - Ground Forces Headquarters, Tours, France
| | - Andrew P Cap
- Medical Corps, US Army, US Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Sylvain Ausset
- French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France
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Fedor PJ, Burns B, Lauria M, Richmond C. Major Trauma Outside a Trauma Center: Prehospital, Emergency Department, and Retrieval Considerations. Emerg Med Clin North Am 2017; 36:203-218. [PMID: 29132578 DOI: 10.1016/j.emc.2017.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Care of the critically injured begins well before the patient arrives at a large academic trauma center. It is important to understand the continuum of care from the point of injury in the prehospital environment, through the local hospital and retrieval, until arrival at a trauma center capable of definitive care. This article highlights the important aspects of trauma assessment and management outside of tertiary or quaternary care hospitals. Key elements of each phase of care are reviewed, including management pearls and institutional strategies to facilitate effective and efficient treatment of trauma patients from the point of injury forward.
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Affiliation(s)
- Preston J Fedor
- Department of Emergency Medicine, Division of Prehospital, Austere and Disaster Medicine, University of New Mexico, 1 University of New Mexico, MSC11 6025, Albuquerque, NM 87131-0001, USA.
| | - Brian Burns
- Greater Sydney Area HEMS, NSW Ambulance, NSW 2200, Australia; Sydney University, Sydney, NSW, Australia
| | - Michael Lauria
- Dartmouth-Hitchcock Advanced Response Team (DHART), Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Clare Richmond
- Greater Sydney Area HEMS, NSW Ambulance, NSW 2200, Australia; Royal Prince Alfred Hospital, Sydney, Australia
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Stone RJ, Guest R, Mahoney P, Lamb D, Gibson C. A 'mixed reality' simulator concept for future Medical Emergency Response Team training. J ROY ARMY MED CORPS 2017; 163:280-287. [PMID: 28062529 DOI: 10.1136/jramc-2016-000726] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/28/2016] [Accepted: 11/30/2016] [Indexed: 11/03/2022]
Abstract
The UK Defence Medical Service's Pre-Hospital Emergency Care (PHEC) capability includes rapid-deployment Medical Emergency Response Teams (MERTs) comprising tri-service trauma consultants, paramedics and specialised nurses, all of whom are qualified to administer emergency care under extreme conditions to improve the survival prospects of combat casualties. The pre-deployment training of MERT personnel is designed to foster individual knowledge, skills and abilities in PHEC and in small team performance and cohesion in 'mission-specific' contexts. Until now, the provision of airborne pre-deployment MERT training had been dependent on either the availability of an operational aircraft (eg, the CH-47 Chinook helicopter) or access to one of only two ground-based facsimiles of the Chinook's rear cargo/passenger cabin. Although MERT training has high priority, there will always be competition with other military taskings for access to helicopter assets (and for other platforms in other branches of the Armed Forces). This paper describes the development of an inexpensive, reconfigurable and transportable MERT training concept based on 'mixed reality' technologies-in effect the 'blending' of real-world objects of training relevance with virtual reality reconstructions of operational contexts.
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Affiliation(s)
| | - R Guest
- University of Birmingham, EESE, Birmingham, UK
| | - P Mahoney
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - D Lamb
- Academic Department of Military Nursing, Royal Centre for Defence Medicine, Birmingham, UK
| | - C Gibson
- Clinical Policy, Royal Army Medical Corps, Royal Centre for Defence Medicine, Birmingham, UK
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Scott T, Hulse E, Haque M, Kirkman E, Hardman J, Mahoney P. Modelling primary blast lung injury: current capability and future direction. J ROY ARMY MED CORPS 2016; 163:84-88. [PMID: 27881470 DOI: 10.1136/jramc-2016-000678] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/18/2016] [Accepted: 10/11/2016] [Indexed: 12/27/2022]
Abstract
Primary blast lung injury frequently complicates military conflict and terrorist attacks on civilian populations. The fact that it occurs in areas of conflict or unpredictable mass casualty events makes clinical study in human casualties implausible. Research in this field is therefore reliant on the use of some form of biological or non-biological surrogate model. This article briefly reviews the modelling work undertaken in this field until now and describes the rationale behind the generation of an in silico physiological model.
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Affiliation(s)
- Timothy Scott
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK
| | - E Hulse
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK
| | - M Haque
- Anaesthesia & Critical Care Research Group, Division of Clinical Neuroscience, Nottingham University Hospital, Queens Medical Centre, Nottingham, UK
| | - E Kirkman
- Defence Science and Technology Laboratories, Salisbury, UK
| | - J Hardman
- Anaesthesia & Critical Care Research Group, Division of Clinical Neuroscience, Nottingham University Hospital, Queens Medical Centre, Nottingham, UK
| | - P Mahoney
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK
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Blackman VS, Cooper BA, Puntillo K, Franck LS. Prevalence and Predictors of Prehospital Pain Assessment and Analgesic Use in Military Trauma Patients, 2010–2013. PREHOSP EMERG CARE 2016; 20:737-751. [DOI: 10.1080/10903127.2016.1182601] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Forward aeromedical evacuation: a brief history, lessons learned from the Global War on Terror, and the way forward for US policy. J Trauma Acute Care Surg 2013; 75:S130-6. [PMID: 23883897 DOI: 10.1097/ta.0b013e318299d189] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Batham D, A F, Kiernan M, Wall C, Simpson RG. Factors Affecting Front Line Casualty Care in Afghanistan. J ROY ARMY MED CORPS 2012; 158:173-80. [DOI: 10.1136/jramc-158-03-05] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Tobin JM, Varon AJ. Review article: update in trauma anesthesiology: perioperative resuscitation management. Anesth Analg 2012; 115:1326-33. [PMID: 22763906 DOI: 10.1213/ane.0b013e3182639f20] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The management of trauma patients has matured significantly since a systematic approach to trauma care was introduced nearly a half century ago. The resuscitation continuum emphasizes the effect that initial therapy has on the outcome of the trauma patient. The initiation of this continuum begins with prompt field medical care and efficient transportation to designated trauma centers, where lifesaving procedures are immediately undertaken. Resuscitation with packed red blood cells and plasma, in parallel with surgical or interventional radiologic source control of bleeding, are the cornerstones of trauma management. Adjunctive pharmacologic therapy can assist with resuscitation. Tranexamic acid is used in Europe with good results, but the drug is slowly being added to the pharmacy formulary of trauma centers in United States. Recombinant factor VIIa can correct abnormal coagulation values, but its outcome benefit is less clear. Vasopressin shows promise in animal studies and case reports, but has not been subjected to a large clinical trial. The concept of "early goal-directed therapy" used in sepsis may be applicable in trauma as well. An early, appropriately aggressive resuscitation with blood products, as well as adjunctive pharmacologic therapy, may attenuate the systemic inflammatory response of trauma. Future investigations will need to determine whether this approach offers a similar survival benefit.
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Affiliation(s)
- Joshua M Tobin
- Department of Anesthesiology, University of Maryland, R Adams Cowley Shock Trauma Center, 22 South Greene St., T1R77, Baltimore, MD 21201, USA.
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Kehoe A, Jones A, Marcus S, Nordmann G, Pope C, Reavley P, Smith C. Current controversies in military pre-hospital critical care. J ROY ARMY MED CORPS 2011; 157:S305-9. [PMID: 22049812 DOI: 10.1136/jramc-157-03s-09] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- A Kehoe
- MDHU Derriford, Derriford Hospital, Plymouth.
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13
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Affiliation(s)
- Geraint Evans
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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Mercer S, Whittle C, Mahoney P. Lessons from the battlefield: human factors in defence anaesthesia. Br J Anaesth 2010; 105:9-20. [DOI: 10.1093/bja/aeq110] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
There are significant differences between the civilian and military pre-hospital trauma systems relating to patient load, injury severity and the nature of the environment. This is reflected in differing clinical paradigm and treatment protocols. There is opportunity, however, for the two systems to learn from each other, which is particularly relevant at the time the UK is actively engaging with defining the requirement for trauma centres and the re-configuration of civilian trauma systems.
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Kirkman E, Watts S, Hodgetts T, Mahoney P, Rawlinson S, Midwinter M. A Proactive Approach to the Coagulopathy of Trauma: The Rationale and Guidelines for Treatment. J ROY ARMY MED CORPS 2007; 153:302-6. [DOI: 10.1136/jramc-153-04-17] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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