Putting Role 1 First: The Role 1 Capability Review

Evolution of First Aid Training in the British Army

INTRODUCTION

This article describes the evolution of first aid in the British Army from the Crimean War to the present day in order to interpret the processes of innovation, implementation, and diffusion of ideas to improve the clinical outcomes for military casualties.

MATERIALS AND METHODS

The article is an analysis of policy and practice for training in first aid published in King's/Queen's Regulations for the Army, the Field Service Pocket Book, or generic military training policy. This is complimented by a review of medical training manuals and a search of articles in the Journal of the Royal Army Medical Corps (RAMC). Most sources have been accessed from the Museum of Military of Medicine and the Wellcome RAMC Muniments Collection.

RESULTS

The narrative summarizes the evolution of clinical concepts in first aid and their translation for Army personnel; starting with RAMC stretcher bearers, extended to soldiers assigned to medical duties at unit level, and finally simplified into first aid training to be taught to all soldiers. Alongside this story of training is a secondary story of the development of field first aid equipment, principally dressings, tourniquets, and analgesia. The final part of the story is the transfer of knowledge from military first aid training into the civilian, community setting. The following themes were identified: the reality of conflict wounds, battlefield first aid is different from civilian first aid, progressive transfer of training from medics to soldiers, transfer of knowledge to civilian sector and internationally, and specific clinical innovations: first field dressings, tourniquets, and prehospital analgesia.

DISCUSSION

The current generation of soldiers are at the highest ever standard of first aid training and equipment. This must be maintained through gathering of evidence in effectiveness and outcomes in prehospital emergency care in both military and civilian settings.

Extending existing recommended military casualty evacuation timelines will likely increase morbidity and mortality: a UK consensus statement

INTRODUCTION

Future conflicts may have limited use of aviation-based prehospital emergency care for evacuation. This will increase the likelihood of extended evacuation timelines and an extended hold at a forward hospital care facility following the completion of damage control surgery or acute medical interventions.

METHODS

A three-round Delphi Study was undertaken using a panel comprising 44 experts from the UK armed forces including clinicians, logisticians, medical planners and commanders. The panel was asked to consider the effect of an extended hold at Deployed Hospital Care (Forward) from the current 2-hour timeline to +4, +8, +12 and +24 hours on a broad range of clinical and logistical issues. Where 75% of respondents had the same opinion, consensus was accepted. Areas where consensus could not be achieved were used to identify future research priorities.

RESULTS

Consensus was reached that increasing timelines would increase the personnel, logistics and equipment support required to provide clinical care. There is a tipping point with a prolonged hold over 8 hours, after which the greatest number of clinical concerns emerge. Additional specialties of surgeons other than general and orthopaedic surgeons will likely be required with holds over 24 hours, and robust telemedicine would not negate this requirement.

CONCLUSIONS

Retaining acute medical emergencies at 4 hours, and head injuries was considered a particular risk. This could potentially be mitigated by an increased forward capacity of some elements of medical care and availability of a CT scanner and intracranial pressure monitoring at over 12 hours. Any efforts to mitigate the effects of prolonged timelines will come at the expense of an increased logistical burden and a reduction in mobility. Ultimately the true effect of prolonged timelines can only be answered by close audit and analysis of clinical outcomes during future operations with an extended hold.

Role of the pre-hospital treatment team on the UK military exercise SAIF SAREEA 3

The prehospital treatment team (PHTT) involves a small team working under the clinical supervision of a clinical lead. The clinical lead can be a general duties medical officer (Post Foundation Years Doctor), military nurse practitioner or more senior clinician. The team is mounted in vehicles appropriate to the environment they expect to operate in. A PHTT is closely located to the front line reducing transportation timelines from the point of wounding to more definitive care. The PHTT can provide medical support on the move or when time is available; a more permanent fully erected treatment facility can be established. Either configuration can provide both trauma and primary care. The size of the team allows for multiple trauma subteams enabling care to casualties that arrive simultaneously. The PHTT can move independently which could leave the team vulnerable as there is no integral force protection within the current structure. In such a small team, the right balance of medical and soldiering skills among team members is essential to success. Exercise SAIF SAREEA 3 represented a large-scale battlegroup exercise to the Middle East in the austere desert of Oman. This provided an ideal environment for employing the PHTT concept is a large deployed force undertaking dynamic activity.

Systematic approach to delivering prolonged field care in a prehospital care environment

BACKGROUND

This article describes a novel patient care algorithm which provides a Role 1 (R1) medic with a structured approach to delivering prolonged field care (PFC) in a resource-limited environment. PFC is a vital component of the operational patient care pathway providing the continuum of care from completion of a primary survey to the delivery to hospital care. Future operational environments are likely to have more fragile or extended lines of communication, potentially delaying evacuation to hospital care. This delay may lead to increases in patient morbidity and mortality. Effective PFC offers an opportunity to improve patient outcomes and help mitigate against this risk.

METHODS

An initial prototype model of a PFC care process was developed using existing hospital-based guidance. A series of medical and trauma vignettes and best available evidence were used to refine the algorithm.

RESULTS

The algorithm has been designed be used in conjunction with patient specific clinical guidance making the approach generalisable for all patient groups. For UK military, clinical guidance is provided by clinical guidelines for operations. The algorithm can be downloaded into a convenient format to be used on mobile devices or printed as an aide memoire.

Lessons from the organisation of the UK medical services deployed in support of Operation TELIC (Iraq) and Operation HERRICK (Afghanistan)

This paper provides the definitive record of the UK Defence Medical Services (DMS) lessons from the organisation of medical services in support of Operation (Op) TELIC (Iraq) and Op HERRICK (Afghanistan). The analysis involved a detailed review of the published academic literature, internal post-operational tour reports and post-tour interviews. The list of lessons was reviewed through three Military Judgement Panel cycles producing the single synthesis 'the golden thread' and eight 'silver bullets' as themes to institutionalise the learning to deliver the golden thread. One additional theme, mentoring indigenous healthcare systems and providers, emerged as a completely new capability requirement. The DMS has established a programme of work to implement these lessons.

Is intramuscular morphine satisfying frontline medical personnels' requirement for battlefield analgesia in Helmand Province, Afghanistan? A questionnaire study

BACKGROUND

All deployed British Army personnel carry intramuscular (IM) morphine auto-injectors to treat battlefield casualties. No other nation supplies parenteral opiate analgesia on individual issue. Studies highlight this agent's inefficacy and safety issues, but are limited by a relative lack of inclusion of frontline personnel. We aimed to determine the opinions of frontline medical personnel on current battlefield analgesia.

METHODS

We surveyed 88 British Army frontline medical personnel (medical officers (n = 12), nurses (n = 7), combat medical technicians (CMTs) (n = 67), paramedics (n = 1) and health-care assistants (n = 1)) upon completion of a six-month deployment (September 2011 to April 2012) to Helmand Province, Afghanistan, using Likert scale questions on the efficacy of battlefield analgesia, complications of IM morphine, safety of morphine auto-injectors and its suitability for treating child casualties.

RESULTS

A total of 88/88 questionnaires were returned. Of these, 61/88 had treated casualties on the battlefield, 26/86 agreed that current battlefield analgesia is effective, 80/87 agreed that a more potent analgesic with a faster onset than IM morphine is desirable in the first hour following injury, 47/65 CMTs agreed that they can manage complications of current battlefield analgesia and 53/86 respondents correctly disagreed that current battlefield analgesia is suitable for child casualties. The potential for accidental self-injection was reported.

CONCLUSIONS

A more potent, faster onset analgesic than IM morphine is desirable in the first hour following injury. Pre-deployment training should emphasise management of complications of opiate analgesics and treatment of child casualties. Oral transmucosal fentanyl citrate is now being issued to all frontline medical personnel. IM morphine will remain on individual issue to all deployed soldiers for environments where an oral agent is not suitable, for example, chemical, biological, radiological and nuclear warfare.

SUMMARY POINTS

Frontline medical personnel agree that a more potent, faster onset analgesic than IM morphine is desirable in the first hour following injury.The two most desirable features of the ideal analgesic were ranked as rapid onset of action, and when fully onset produces a high degree of pain relief.Oral transmucosal fentanyl citrate (OTFC) has now been issued to all frontline medical personnel as an adjunct to IM morphine.IM morphine will remain on individual issue for situations where parenteral analgesia is required.Consideration should be given to individual issue of OTFC to all deployed personnel in the future.Pre-deployment training should emphasise management of complications of opiate analgesics and treatment of child casualties.

A system for the management, display and integration of pre-hospital healthcare activity in the deployed environment

AIM

To create and implement a system through which pre-hospital healthcare activity across an entire operational theatre could be made available in real-time to support healthcare delivery, governance and assurance activity.

METHODS

An IT-based system was created that could display, manage and integrate the pre-hospital healthcare activity on Op HERRICK 18. The system was based on the Defence Medical Services Common Assurance Framework and run through Microsoft Office SharePoint.

RESULTS

Pre-hospital healthcare activity was made available and visible across an operational theatre. This supported delivery, assurance and governance at any time. Activity from each medical facility could be integrated and display automatically improving theatre wide situational awareness. The availability of information resulted in a shift towards a more continuous process of assurance and governance rather than reliance on inherently threatening and increasingly intermittent inspection regimes.

DISCUSSION

The ability to review healthcare activity remotely at anytime significantly improves the validity of assurance possible for a deployed force. Governance activity can be more responsive and less reliant on the fixed timescale and datasets of reports from outlying medical facilities. However, assurance and governance authorities must not allow such a wealth of information to impact local leadership and innovation through a perception of, or actual, micro-management.

Firebase medicine: extending the Role I aid station

The unique nature of counterinsurgency warfare in Afghanistan highlights the tactical and technical challenges of the non-contiguous battlefield. Although remote military outposts distant from their support hubs help project NATO power, they also operate without the advantages of a secure rear area or interior lines of communication. Commonly referred to as 'firebases', these outposts typically house a platoon or company-sized element and present numerous challenges to the delivery of medical care and support. Medical planners and providers can mitigate many of these inherent risks through targeted interventions designed to increase the capabilities of these remote outposts. These interventions include focused higher-level trauma and non-trauma medical training for both medical and non-medical personnel, expanded equipment lists, ongoing medical education, training and rehearsals, and a proven and redundant communications plan.

The Role 1 capability review: mitigation and innovation for Op HERRICK 18 and into contingency

The Role 1 orientated JRAMC of September 2012 was a welcome addition to the body of Role 1 literature. In particular, the Role 1 capability review by Hodgetts and Findlay detailed both current issues and future aspirations for Role 1 provision. This personal view considers issues still prevalent during Op HERRICK 18 namely the provision of primary healthcare by combat medical technicians on operations and the organisational issues that contribute to historical structural and attitudinal obstructions to the employment of combat medical technicians in firm base primary healthcare. It also considers a dynamically updating dashboard capable of displaying risk across the Role 1 network with the implied move to a model of continuous healthcare assurance.