Military Anaesthesia in contingencies: what skill sets are required and how will we prepare our trainees?

European military surgical teams in combat theater: A survey study on deployment preparation and experience

INTRODUCTION

Adequate (predeployment) training of the nowadays highly specialized Western military surgical teams is vital to ensure a broad range of surgical skills to treat combat casualties. This survey study aimed to assess the self-perceived preparedness, training needs, deployment experience, and post-deployment impact of surgical teams deployed with the Danish, Dutch, or Finnish Armed Forces. Study findings may facilitate a customized predeployment training.

METHODS

A questionnaire was distributed among Danish, Dutch, and Finnish military surgical teams deployed between January 2013 and December 2020 (N = 142). The primary endpoint of self-perceived preparedness ratings, and data on the training needs, deployment experiences, and post-deployment impacts were compared between professions and nations.

RESULTS

The respondents comprised 35 surgeons, 25 anesthesiologists, and 39 supporting staff members, with a response rate of 69.7 % (99/142). Self-perceived deployment preparedness was rated with a median of 4.0 (IQR 4.0-4.0; scale: 1 [very unprepared]-5 [more than sufficient]). No differences were found among professions and nations. Skills that surgeons rated below average (median <6.0; scale: 1 [low]-10 [high]) included tropical disease management and maxillofacial, neurological, gynecological, ophthalmic, and nerve repair surgery. The deployment caseload was most often reported as <1 case per week (41/99, 41.4 %). The need for professional psychological help was rated at a median of 1.0 (IQR 1.0-1.0; scale: 1 [not at all]-5 [very much]).

CONCLUSIONS

Military surgical teams report overall adequate preparedness for deployment. Challenges remain for establishing broadly skilled teams because of a low deployment caseload and ongoing primary specializations. Additional training and exposure were indicated for several specialism-specific skill areas. The need for specific training should be addressed through customized predeployment programs.

Can Defence be assured that future civilian specialty training programmes will produce suitably qualified and experienced military doctors?

UK Defence's doctors receive the majority of their pre-accreditation clinical training within the National Health Service's (NHS) specialty training programmes. These are designed primarily to serve the needs of a civilian patient population and are undergoing changes. Examination of these changes in relation to the training requirements of Defence's doctors, suggests that future NHS training programmes present both opportunity and threat to the provision of competent military consultants and general practitioners (GPs). Opportunity to more easily integrate military-specific courses, experience and modules will be present in the form of curricula that are more receptive to change and more flexible with respect to time out of programme. This offers definite advantage in terms of ability to robustly equip military doctors with the skills required to serve their future patients. Narrowing scopes of practice and a reduction in acute care exposure for GPs are potential future threats.

Parenteral medications at Role 1: do doctors in the British Army require improved training and experience?

Role 1 doctors in the British Army work predominantly in primary healthcare, but also provide prehospital emergency care and administer potent parenteral medications in the field. Role 1 doctors have theoretical training in the use of these medications on short courses but then have little refresher training and use them infrequently in their routine practice, introducing the risk of skill fade. This may lead to higher rates of medication errors in an environment where the consequences may be significant. This article explores the current training of Role 1 doctors, the threat of skill fade and how the safety of drug administration can be improved. This includes recommendations for the development of training competencies, bespoke courses and clinical placements, e-learning and the use of new technology. Application of these recommendations has the potential to improve patient safety and the confidence of doctors in the use of parenteral analgesia.

The French Pre-Deployment Advanced Course in Anesthesia and Resuscitation: Development and Future Prospects

INTRODUCTION

Military anesthesiologists from the French Military Medical Service (FMMS) are part of the Forward Surgical Teams deployed in overseas military operations. The practice of anesthesia in combat zones requires specific skills that are not taught during the initial curriculum for French civilian anesthesiologist. The Pre-Deployment Advanced Course in Anesthesia and Resuscitation (DACAR) program was developed to prepare military anesthesiologist from the FMMS before their deployment in overseas military operations.

METHODS

Created in 2013 by the French Military Medical Academy, the DACAR program is divided into two modules and carried out once a year. The DACAR program trains all military anesthesiologist residents at the end of their curricula. Since 2019, a number of Certified Registered Nurse Anesthetists have completed the DACAR program. The DACAR program is organized around the main axes of experience feedback from previous deployments in combat zones as well as didactic learning and practical training using high-fidelity simulation.

RESULTS

Since 2013, a total of 99 trainees completed the DACAR program during six complete cycles of two modules. The DACAR program has gradually been enriched from 14 courses in 2013 to 28 in 2019. Participants' reported satisfaction rates have increased steadily since 2016, when 88% of courses were rated as "interesting" or "very interesting," and only 4% as "not very interesting." By 2019, those figures had improved to 96% and 2%, respectively.

CONCLUSION

The DACAR program is a structured and adapted military medical course aimed at completing the curriculum of military anesthesiologists from the FMMS before deployment in overseas military operations. Regular audits and updates ensure that the DACAR training program maintains the highest standards of quality and rigor.

Association between traumatic brain injuries and ketamine infusion side effects following combat injury

INTRODUCTION

Ketamine is a vital component for acute pain management in emergency trauma care for both civilian and military hospitals. This preliminary analysis examined whether combat-injured US service members sustaining traumatic brain injuries (TBI) experienced increased odds of ketamine side effects compared with those without TBI.

METHODS

This preliminary analysis included combat-injured service members, ages ≥18 years with documented pain scores during the 24 hours before and 48 hours after receiving an intravenous ketamine infusion at Walter Reed National Military Medical Center (WRNMMC) between 2007 and 2014. Logistic regression modeling examined the association between TBI and ketamine side effects (eg, hallucinations, nightmares, dysphoria, nausea, decreased oxygen saturation) during hospitalisation.

RESULTS

Of the 77 patients, 62% presented with a documented TBI. Side effects were documented for 18.8% of those without TBI and 24.4% of those with TBI. Analyses were unable to find evidence against the null hypothesis with the current sample size, even when adjusting for injury characteristics and preinfusion opioid doses (adjusted OR=0.90 (95% CI 0.26 to 3.34), p=0.87).

CONCLUSION

In this small sample of combat-injured service members, we were unable to detect a difference in ketamine-related side effects by documented TBI status. These hypothesis-generating findings support the need for future studies to examine the use of intravenous ketamine infusions for pain management, and subsequent care outcomes in patients who experience polytraumatic trauma inclusive of TBI.

Paediatrics on exercise ASKARI SERPENT: reflections and recommendations for pre-deployment training

The British Army has a long history of training in Kenya, including delivering health outreach to the local population on Exercise ASKARI SERPENT. This article presents data from two iterations of Exercise ASKARI SERPENT in which children accounted for almost 40% of all patients treated. Short case vignettes highlight the technical and non-technical challenges faced when treating children, before recommendations are made for pre-deployment training for Exercise ASKARI SERPENT and similar future deployments which may see military clinicians delivering treatment to the local population.