Military pre-hospital care: why is it different?

Defining capabilities in deployed UK military prehospital emergency care

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.

Transfer of Clinical Decision-Making-Related Learning Outcomes Following Simulation-Based Education in Nursing and Medicine: A Scoping Review

PURPOSE

Simulation is often depicted as an effective tool for clinical decision-making education. Yet, there is a paucity of data regarding transfer of learning related to clinical decision-making following simulation-based education. The authors conducted a scoping review to map the literature regarding transfer of clinical decision-making learning outcomes following simulation-based education in nursing or medicine.

METHOD

Based on the Joanna Briggs Institute methodology, the authors searched 5 databases (CINAHL, ERIC, MEDLINE, PsycINFO, and Web of Science) in May 2020 for quantitative studies in which the clinical decision-making performance of nursing and medical students or professionals was assessed following simulation-based education. Data items were extracted and coded. Codes were organized and hierarchized into patterns to describe conceptualizations and conditions of transfer, as well as learning outcomes related to clinical decision-making and assessment methods.

RESULTS

From 5,969 unique records, 61 articles were included. Only 7 studies (11%) assessed transfer to clinical practice. In the remaining 54 studies (89%), transfer was exclusively assessed in simulations that often included one or more variations in simulation features (e.g., scenarios, modalities, duration, and learner roles; 50, 82%). Learners' clinical decision-making, including data gathering, cue recognition, diagnoses, and/or management of clinical issues, was assessed using checklists, rubrics, and/or nontechnical skills ratings.

CONCLUSIONS

Research on simulation-based education has focused disproportionately on the transfer of learning from one simulation to another, and little evidence exists regarding transfer to clinical practice. The heterogeneity in conditions of transfer observed represents a substantial challenge in evaluating the effect of simulation-based education. The findings suggest that 3 dimensions of clinical decision-making performance are amenable to assessment-execution, accuracy, and speed-and that simulation-based learning related to clinical decision-making is predominantly understood as a gain in generalizable skills that can be easily applied from one context to another.

Mapping the Steroid Response to Major Trauma From Injury to Recovery: A Prospective Cohort Study

CONTEXT

Survival rates after severe injury are improving, but complication rates and outcomes are variable.

OBJECTIVE

This cohort study addressed the lack of longitudinal data on the steroid response to major trauma and during recovery.

DESIGN

We undertook a prospective, observational cohort study from time of injury to 6 months postinjury at a major UK trauma centre and a military rehabilitation unit, studying patients within 24 hours of major trauma (estimated New Injury Severity Score (NISS) > 15).

MAIN OUTCOME MEASURES

We measured adrenal and gonadal steroids in serum and 24-hour urine by mass spectrometry, assessed muscle loss by ultrasound and nitrogen excretion, and recorded clinical outcomes (ventilator days, length of hospital stay, opioid use, incidence of organ dysfunction, and sepsis); results were analyzed by generalized mixed-effect linear models.

FINDINGS

We screened 996 multiple injured adults, approached 106, and recruited 95 eligible patients; 87 survived. We analyzed all male survivors <50 years not treated with steroids (N = 60; median age 27 [interquartile range 24-31] years; median NISS 34 [29-44]). Urinary nitrogen excretion and muscle loss peaked after 1 and 6 weeks, respectively. Serum testosterone, dehydroepiandrosterone, and dehydroepiandrosterone sulfate decreased immediately after trauma and took 2, 4, and more than 6 months, respectively, to recover; opioid treatment delayed dehydroepiandrosterone recovery in a dose-dependent fashion. Androgens and precursors correlated with SOFA score and probability of sepsis.

CONCLUSION

The catabolic response to severe injury was accompanied by acute and sustained androgen suppression. Whether androgen supplementation improves health outcomes after major trauma requires further investigation.

Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study

BACKGROUND

Intraosseous (IO) drug infusion has been reported to have similar pharmacokinetics to intravenous (IV) infusion. In military and civilian trauma, the IO route is often used to obtain rapid and reliable parenteral access for drug administration. Only a few case reports have described the use of IO infusion to administer drugs for rapid sequence induction of anaesthesia (RSI).

OBJECTIVE

We aimed to assess the feasibility of the administration of RSI drugs via an IO catheter in a prospective observational study.

METHODS

A prospective observational study was undertaken at a combat hospital in Afghanistan. A validated data form was used to record the use of IO drugs for RSI by the prehospital, physician-led Medical Emergency Response Team (MERT), and by inhospital physicians. Data were captured between January and May 2012 by interview with MERT physicians and inhospital physicians directly after RSI. The primary outcome measure was the success rate of first-pass intubation with direct laryngoscopy.

RESULTS

34 trauma patients (29 MERT and 5 inhospital) underwent RSI with IO drug administration. The median age was 24 years and median injury severity score 25; all were male. The predominant mechanism of injury was blast (n=24), followed by penetrating (n=6), blunt (n=3) and burn (n=1). First-pass intubation success rate was 97% (95% CI 91% to 100%). A Cormack-Lehane grade 1 view, by direct laryngoscopy, was obtained at first look in 91% (95% CI 81% to 100%) of patients.

CONCLUSIONS

In this prospective, observational study, IO drug administration was successfully used for trauma RSI, with a comparable first pass intubation success than published studies describing the IV route.

TRIAL REGISTRATION NUMBER

RCDM/Res/Audit/1036/12/0162.

Resuscitative thoracotomy following wartime injury

BACKGROUND

The evidence for resuscitative thoracotomy (RT) in trauma patients following wartime injury is limited; its indications and timings are less defined in battle injury. The aim of this study was to analyze survival as well as the causes and times of death in patients undergoing RT within the context of modern battlefield resuscitation.

METHODS

A retrospective cohort study was performed on consecutive admissions to a Field Hospital in Southern Afghanistan. All patients undergoing RT were identified using the UK Joint Theatre Trauma Registry. The primary outcome was 30-day mortality, and secondary outcomes included location of cardiac arrest, time from arrest to thoracotomy, and proportion achieving a return of spontaneous circulation.

RESULTS

Between April 2006 to March 2011, 65 patients underwent RT with 14 survivors (21.5%). Ten patients (15.4%) had an arrest in the field with no survivors, 29 (44.6%) had an arrest en route with 3 survivors, and 26 (40.0%) had an arrest in the emergency department with 11 survivors. There was no difference in Injury Severity Scores (ISSs) between survivors and fatalities (27.3 [7.6] vs. 36.0 [22.1], p = 0.636). Survivors had a significantly shorter time to thoracotomy than did fatalities (6.15 [5.8] minutes vs. 17.7 [12.63] minutes, p < 0.001).

CONCLUSION

RT following combat injury will yield survivors. Best outcomes are in patients who have an arrest in the emergency department or on admission to the hospital.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level III.

Clinical review: Canadian National Advisory Committee on Blood and Blood Products--Massive transfusion consensus conference 2011: report of the panel

In June 2011 the Canadian National Advisory Committee on Blood and Blood Products sponsored an international consensus conference on transfusion and trauma. A panel of 10 experts and two external advisors reviewed the current medical literature and information presented at the conference by invited international speakers and attendees. The Consensus Panel addressed six specific questions on the topic of blood transfusion in trauma. The questions focused on: ratio-based blood resuscitation in trauma patients; the impact of survivorship bias in current research conclusions; the value of nonplasma coagulation products; the role of protocols for delivery of urgent transfusion; the merits of traditional laboratory monitoring compared with measures of clot viscoelasticity; and opportunities for future research. Key findings include a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, the expected value of an organized response plan, and the recommendation for an integrated approach that includes antifibrinolytics, rapid release of red blood cells, and a foundation ratio of blood components adjusted by results from either traditional coagulation tests or clot viscoelasticity or both. The present report is intended to provide guidance to practitioners, hospitals, and policy-makers.

New approaches to the management of traumatic external haemorrhage

Uncontrolled external haemorrhage, though rare in civilian practice, is responsible for up to 80% of pre-hospital deaths in military trauma. Data from recent conflicts shows that exsanguination before evacuation accounts for 50% of deaths. Severe haemorrhage leads to the lethal triad of acidosis, hypothermia and coagulopathy. A new treatment paradigm, <C>ABC (where <C> stands for ‘Control of catastrophic haemorrhage) has been used to prioritise management of external haemorrhage. This approach has been augmented by the use of elastic field dressings, tourniquets and haemostatic agents. A ‘ladder’ approach is used to ensure basic wound management techniques are adopted before more sophisticated ones. Early fluid replacement via intraosseous needles and using blood and other blood products in the pre-hospital environment are other strategies used to achieve early haemostasis.

Entering a new paradigm: emergency nursing into the 21st Century

Two National Audit Office reports were published in February 2010. The first was highly critical of emergency healthcare delivery in England and highlighted the ways in which staffing and resource allocations could be areas that could have a negative impact on morbidity and mortality. The second report highlighted the significant positive impact that current military emergency care is making with focused training and development of all professionals contributing to the care delivery strategies. This article evaluates the two publications and emphasises on the contribution that appropriately educated, prepared and trained emergency nurses could make within the NHS context.