Corruption in emergency procurement

Corruption in emergency procurement reduces the resources available for life-saving operations, lowers the quality of products and services provided, and diverts aid from those who need it most.(1) It also negatively influences public support for humanitarian relief, both in the affected country and abroad. This paper aims to unpack and analyse the following question in order to mitigate risk: how and where does corruption typically occur, and what can be done? Suggested strategies reflect a multi-layered approach that stresses internal agency control mechanisms, conflict-sensitive management, and the need for common systems among operators.

Health facilities planning: determining infrastructure requirements for form and function from clinical and operational capabilities

This article describes the practical application of documenting the operational concept and scope of services for military combat hospitals providing joint health service support during Operation Iraqi Freedom. Due to the rapid changes that take place in healthcare in general, and, in particular, in a large, rapidly maturing military theater of operations, a clear operational concept and accurate scope of services is essential for hospital commanders and medical planners. A highly structured, yet flexible collaborative approach to health facility requirements development begins with a clinical concept of operations (CONOPS). Initial, up-front investment of time in the requirements process, and subsequent reviews and revisions result in a definitive description of the clinical and operational requirements. Those requirements in turn become the authoritative source for space, building systems, equipment, functional arrangements, and financial justification. A recent case study highlights the utility of the CONOPS document in translating the necessary clinical capabilities and capacities into facility space and building systems required to support them in a very tight schedule driven process normally not associated with the military construction program and in particular medical projects.

Army field surgical experience

In the recent Falklands campaign four Army Field Surgical Teams were deployed in the two phases of the war. They functioned as Advanced Surgical Centres and operated on 233 casualties. There were 3 deaths. The patterns of wounding and the methods of casualty management are discussed and compared with other recent campaigns.

Mass medical evacuation: Hurricane Katrina and nursing experiences at the New Orleans airport

Hurricane Katrina, a category 4 storm, struck the U.S. Gulf states in late August, 2005, resulting in the most costly and second most deadly natural disaster in recent United States history. The storm and subsequent flooding due to levee failure necessitated the evacuation of 80% of the city of New Orleans' 484,674 residents. Most of the city's hospitals and other health care resources were destroyed or inoperable. The hurricane devastated many communities, stranding people in hospitals, shelters, homes, and nursing homes. Nurses and other health care providers deployed to New Orleans to provide medical assistance experienced substantial challenges in making triage and treatment decisions for patients whose numbers far exceeded supplies and personnel. This article describes the experiences and solutions of nurses and other personnel from 3 Disaster Medical Assistance Teams assigned to the New Orleans airport responsible for perhaps the most massive patient assessment, stabilization, and evacuation operation in U.S. history. As the frequency of disasters continues to rise, it is imperative that the nursing profession realize its value in the disaster arena and continually take leadership roles.

The role of local steroid injections in an operational field hospital setting

OBJECTIVES

To assess the safety and effectiveness of administering local steroid injections in an operational field hospital environment.

METHOD

A prospective study of patients presenting to the physiotherapy department at the British Military Hospital (BMH) Shaibah, Iraq was undertaken from July 2006 - September 2006. Patients with a condition amenable to local steroid injection and who had not improved with conservative therapy were considered for the study. They then underwent local injection with steroid and local anaesthetic.

RESULTS

During this period 12 patients were identified that fitted the criteria for local steroid injection. This represented 7% (12/179) of patients who were seen by the physiotherapy department in either an in or out-patient setting. All patients were injected with local anaesthetic and steroid injection with a single dose of intravenous antibiotic as antimicrobial cover. 10/12 (83.3%) were able to return to their unit within this theatre of operation. The only complication was one case of post injection flare of pain, which settled after 48 hours.

CONCLUSION

The use of local steroid injection, as an adjunct to physical therapy, can enable service personnel to remain in the theatre of operations. These patients may have otherwise required aero medical evacuation. We consider the use of a local steroid injection to be a safe and effective intervention in certain patients where conservative measures alone do not work. This study highlights the safety of using steroid injections in an operational field hospital setting. Further large scale studies may help corroborate this conclusion.

United States military surgical response to modern large-scale conflicts: the ongoing evolution of a trauma system

This article provides a brief description of the evolution of military trauma surgical care since Operation Desert Storm and the ongoing evolution of the trauma system in Operation Iraqi Freedom.

Ketamine for procedural sedation and analgesia by nonanesthesiologists in the field: a review for military health care providers

Military health care providers located in field environments frequently face situations in which procedural sedation and analgesia are necessary, without the advantage of sophisticated monitoring equipment. Ketamine is a unique agent that can be administered either intravenously or intramuscularly to produce predictable and profound analgesia, with an exceptional safety profile. We review the issues unique to ketamine and provide a practical guide for the use of ketamine for adult and pediatric patients in a field environment.

Endoscopy in a deployed combat support hospital: maintaining military end-strength

OBJECTIVE

The objective was to examine the safety and efficacy of the 48th Combat Support Hospital's use of diagnostic endoscopy in Afghanistan.

METHODS

A retrospective review was performed on the medical records of all endoscopy patients treated at the 48th Combat Support Hospital in Bagram, Afghanistan, from December 6, 2002 through June 7, 2003.

RESULTS

Twenty-four patients (male, 21; female, 3; mean age, 35 years) underwent 28 endoscopic procedures as follows: colonoscopy, 14; esophagogastroduodenoscopy (EGD), 13; and flexible sigmoidoscopy, 1. Four patients underwent both EGD and colonoscopy. There were no complications. Of the 18 U.S. military patients, 3 (15%) were evacuated for further evaluation and/or treatment and 1 (5%) patient underwent an elective screening colonoscopy. For 14 of 17 U.S. military personnel (82%), the endoscopic procedures obviated evacuation from Afghanistan.

CONCLUSIONS

Diagnostic colonoscopy and EGD were valuable and safe adjuncts that precluded evacuations out of theater for 82% of military patients. Endoscopy should be used when U.S. military operations necessitate the deployment of large numbers of forces for protracted periods.

A novel device developed, tested, and used for warming and maintaining intravenous fluids in a forward surgical team during Operation Enduring Freedom

OBJECTIVE

To determine whether an accessory to the Bair Hugger warming unit (BHWU), a piece of equipment intrinsic to the forward surgical team, could be designed and used to warm and to maintain large volumes of intravenous fluids at an optimal infusion temperature in an austere environment.

METHODS

The X-1 is a simple, collapsible, 5-gallon nylon cooler with handles, modified with a port for the BHWU hose and a one-way flutter valve vent.

RESULTS

The warming of intravenous fluids to the optimal infusion temperature was accomplished with the BHWU and X-1. The warming time was influenced by the ambient temperature, the starting temperature of the fluids, and the number of bags being warmed. The warmed fluid could be stored and maintained in the X-1. The heat retention of the fluids was influenced by the ambient temperature, the number of bags warmed, and the insulating properties of the X-1.

CONCLUSIONS

The BHWU can be used with the compact X-1 to warm and to store large volumes of intravenous fluids at the optimal infusion temperature in the field environment and was successfully used by a forward surgical team in Afghanistan, during Operation Enduring Freedom, for the treatment of combat-wounded soldiers.

The Army forward surgical team: update and lessons learned, 1997-2004

Although the U.S. Army stood up two prototype airborne forward surgical teams (FSTs) in the early 1990s, it officially fielded the first 20-man FST in March 1997. Since then, Army FSTs (of which there are now 14 active and 23 reserve) have deployed on numerous combat, peacekeeping, and disaster-relief missions throughout the world. Although initially designed primarily for forward resuscitative surgery in support of short-term, offensive combat operations, the FST has become one of the Army Medical Department's most frequently deployed "long-term" health care facilities, i.e., long-term for the assigned personnel. The purpose of this article was to review the history of the FST, define its mission, delineate pitfalls in its employment and to make personnel and material acquisition recommendations for the future.

Forward surgery on Operation Telic--Iraq 2003

Two Air Assault Surgical Groups (AASGs) from 16 Close Support Medical Regiment deployed to Kuwait on Operation Telic in February 2003. Each AASG was comprised of a four-table resuscitation facility, a two table FST and a twin-bedded ITU facility. An A+E Consultant and nurse, an experienced radiographer and laboratory technician with two further RGNs and CMTs provided resuscitation support. Each FST had an orthopaedic and a general surgeon, two anaesthetists and eight operating department practitioners. Further equipment consisted of a Polymobil 111 X-ray unit, a Sonosite 180 ultrasound scanner and an ISTAT gas, haematocrit and electrolyte analyser. 100 units of mixed blood were carried by each AASG. Fifty-one surgical procedures were performed on thirty one patients. Twenty one of these patients were Iraqi prisoners of war or civilians. Seventeen wound debridements, five amputations, five laparotomies, four insertions of Denham pins with Thomas splintage for femoral fracture, three external fixations and one axillary artery repair formed the basis of the major cases undertaken. The first field use of activated factor VII by the British Army was successful in the resuscitation of a patient with exsanguinating haemorrhage after an open-book (APC-III) pelvic fracture and a ruptured intrapelvic haematoma. The other cases included eleven manipulations under anaesthetic/application of plaster and four finger terminalisations. Forward military surgery has a continued role to play on the modern fast moving battlefield. 16 Close Support Medical Regiment normally supports 16 Air Assault Brigade with its remit for expeditionary operations and SF support. Its experience on Op Telic should influence planning for future deployment.

Successful Removal of a Cerebellar Hemangioblastoma in a Combat Support Hospital

The case of a 24-year-old male U.S. Marine Corps sergeant who presented with headache and ataxia to a combat support hospital (CSH) in Kuwait, during Operation Iraqi Freedom, is described. Imaging studies revealed a cystic brain neoplasm causing hydrocephalus and increased intracranial pressure. Because of the patient's deteriorating clinical condition and the high risk of further brain injury during a prolonged air evacuation flight, immediate surgery at the CSH was deemed the safest treatment option. The tumor was completely removed and the patient's symptoms resolved, allowing safe evacuation. A CSH is not intended to provide comprehensive neurosurgical capabilities and some equipment usually considered necessary to perform this surgery was unavailable, but field-expedient methods were devised to overcome these deficiencies. This is the first reported case of a brain tumor successfully removed in a CSH.

Extremity Vascular Injuries on the Battlefield: Tips for Surgeons Deploying to War

BACKGROUND

Recent events have refocused attention on certain principles regarding the surgical management of casualties on the battlefield. Extremity vascular injuries predominate, representing 50 to 70% of all injuries treated during Operation Iraqi Freedom, and exsanguination from extremity wounds is the leading cause of preventable death on the modern battlefield. Recent advances in military medicine have translated into a greater percentage of wounded soldiers surviving during Operations Enduring and Iraqi Freedom than in any other previous American conflict. The combat-experienced military surgeon, a fraction of those in uniform until recently, rarely has had the opportunity to convey lessons learned to the newly indoctrinated war surgeon. The purpose of this review is to do exactly that.

METHODS

We collectively reviewed the experience and opinions of five U.S. Army surgeons with regard to management of extremity vascular injuries in a combat zone

RESULTS

The modern battlefield has a staunch reputation of being unclean, noisy, and lacking of valuable resources. High-kinetic energy injuries such as those resulting from high explosives, munitions, and high-velocity missiles often cause soft-tissue destruction that is not routinely seen in civilian settings. Military-specific considerations in the management of these injuries are reviewed.

CONCLUSIONS

The management of extremity vascular injuries on the modern battlefield presents many unique and demanding challenges to even the most seasoned of surgeons. Preparation goes a long way in overcoming some of the obstacles to seamless patient care.

Computed Tomography of Craniofacial Trauma at a Combat Support Hospital in Afghanistan

Complex craniofacial injuries are encountered among both soldiers and civilians in combat zones. Computed tomography is a necessary and effective tool for the evaluation and treatment of these injuries in the forward-deployed combat support hospital.

Air Force expeditionary medical support unit at the Houston floods: use of a military model in civilian disaster response

From June 6 to 10, 2001, Tropical Storm Allison delivered 40 inches of rain to the city of Houston, Texas. Nine of the city's hospitals were closed or severely curtailed services as a result of the flooding. All area hospitals were full to capacity, intensive care unit beds were unavailable, and patient wait times for emergency department care were 18 to 21 hours. Emergency department and intensive care unit congestion placed the entire emergency medical system of Houston in jeopardy. In response to a Federal Emergency Management Agency request, the Air Force deployed a 25-bed expeditionary medical support field hospital to Houston on June 13, 2001. The expeditionary medical support unit treated its first patient only 3.5 hours after arrival and was fully operational 8 hours later. During its 11-day stay, the facility treated 1,036 patients, including 312 ambulance arrivals, 48 inpatients, and 33 intensive care unit patients, and performed 33 dental procedures and 16 operations.

Ultrasonography in a forward-deployed military hospital

Military medical units must be flexible and mobile to keep up with maneuver units on the modern battlefield. The requirements for unit mobility and maneuverability preclude bulky advanced radiologic imaging support, such as computed tomography or magnetic resonance imaging systems. Portable sonography is rapid, reliable, efficient, and user-friendly; it markedly expanded the diagnostic capability of our forward-deployed combat support hospital during Operation Iraqi Freedom. More than 400 ultrasound studies were performed during the first 6 months of hospital operations in Iraq. The use of this technology on the battlefield improved our ability to provide definitive, quality, medical care far forward and to preserve the fighting strength of supported units.

Diagnosis and treatment of a ruptured ectopic pregnancy in a combat support hospital during Operation Iraqi Freedom: case report and critique of a field-ready sonographic device

This case report describes a novel diagnostic approach for ectopic pregnancy in a combat environment. We diagnosed a ruptured ectopic pregnancy at our combat support hospital by using the SonoSite 180 Plus ultrasound device (SonoSite, Bothell, WA). The live ectopic pregnancy was immediately identified and the entire pelvic anatomy was easily assessed within 5 minutes. The SonoSite ultrasound device proved to be easy to use, durable, and reliable. It produced high-quality images in a variety of applications. The handheld SonoSite 180 ultrasound device is sufficiently portable to be used effectively in a combat support hospital or field situation, such as a forward surgical team. This combat experience suggests that a handheld ultrasound device may also have great utility during patient transport for civilian hospitals.

Policy development in disaster preparedness and management: lessons learned from the January 2001 earthquake in Gujarat, India

INTRODUCTION

During the last decades, several humanitarian emergencies have occurred, with an increasing number of humanitarian organizations taking part in providing assistance. However, need assessments, medical intelligence, and coordination of the aid often are sparse, resulting in the provision of ineffective and expensive assistance. When an earthquake with the strength of 7.7 on the Richter scale struck the state of Gujarat, India, during the early morning on 26 January 2001, nearly 20,000 persons were killed, nearly 170,000 were injured, and 600,000 were rendered homeless. This study identifies how assigned indicators to measure the level of health care may improve disaster preparedness and management, thus, reducing human suffering.

METHODS

During a two-week mission in the disaster area, the disaster relief provided to the disaster-affected population of Gujarat was evaluated. Vulnerability due to climate, geography, culture, religion, gender, politics, and economy, as each affected the outcome, was studied. By assigning indicators to the eight ELEMENTS of the Primary Health Care System as advocated by the World Health Organization (WHO), the level of public health and healthcare services were estimated, an evaluation of the impact of the disaster was conducted, and possible methods for improving disaster management are suggested. Representatives of the major relief organizations involved were interviewed on their relief policies. Strategies to improve disaster relief, such as policy development in the different aspects of public health/primary health care, were sought.

RESULTS

Evaluation of the pre-event status of the affected society revealed a complex situation in a vulnerable society with substantial deficiencies in the existing health system that added to the severity of the disaster. Most of the civilian hospitals had collapsed, and army field hospitals provided medical care to most of the patients under primitive conditions using tents. When the foreign field hospitals arrived five to seven days after the earthquake, most of the casualties requiring surgical intervention already had been operated on. Relief provided to the disaster victims had reduced quality for the following reasons: (1) proper public health indicators had not yet been developed; (2) efficient coordination was lacking, (3) insufficient, overestimated, or partly irrelevant relief was provided; (4) relief was delayed because of bureaucracy; and (5) policies on the delivery of disaster relief had not been developed.

CONCLUSION

To optimize the effectiveness of limited resources, disaster preparedness and the provision of feasible and necessary aid is of utmost importance. An appropriate, rapid, crisis intervention could be achieved by continual surveillance of the world's situation by a Relief Coordination Center. A panel of experts could evaluate and coordinate the international disaster responses and make use of stored emergency material and emergency teams. A successful disaster response will depend on accurate and relevant medical intelligence and socio-geographical mapping in advance of, during, and after the event(s) causing the disaster. More effective and feasible equipment coordinated with the relief provided by the rest of the world is necessary. If policies and agreements are developed as part of disaster preparedness, on international, bilateral, and national levels, disaster relief may be more relevant, less chaotic, and easier to estimate, thus, bringing improved relief to the disaster victims.

Planning for mass civilian casualties overseas: IMSuRT-International Medical/Surgical Response Teams

The increased likelihood of mass casualties involving Americans living abroad has prompted the development of a mobile, civilian medical and surgical unit available for rapid deployment overseas. Using past experience derived from the National Disaster Medical Service, and from recent rescue efforts following the African embassy bombings in 1998, an International Medical-Surgical Response Team was developed. Organized under the Department of Homeland Security, it is staffed by civilian professionals from medical and bioengineering fields. Initial deployments to the World Trade Center (2001) and Guam (2002) have shown the ability to rapidly mobilize appropriate manpower and equipment to a mass casualty site, whether domestic or international. The goals of this organization are to work in cooperation with local authorities at the mass casualty site to provide rapid assessment and medical stabilization of injured persons. When the mass casualty is overseas, rapid evacuation of casualties is accomplished by the responding military air evacuation service.

The Implications of TRICARE on Medical Readiness

The objective of this study was to compare two alternative sources of replacement personnel for a medical treatment facility experiencing personnel loss due to a deployment. The two replacement strategies included the reserve component option and the TRICARE internal resource-sharing option. A hypothetical scenario was used as a mechanism for the analysis, and three key variables were considered: effectiveness, feasibility, and operational expense. From the perspective of effectiveness, the TRICARE strategy demonstrated an ability to provide a slightly larger percentage of the requested replacement personnel. With regard to feasibility, both strategies were feasible in that both could provide replacements for the duration of the 270-day deployment and within an established 180-day report date. Operational expense was a decisive factor with the reserve component option significantly less costly than the TRICARE alternative. Weaknesses and strengths of each option were identified and discussed, and alternatives were recommended.

Surgical support of Operation Sea Signal: adaptability of the 59th Air Transportable Hospital in Cuba

OBJECTIVE

The attempted migration of approximately 50,000 Cubans in the summer of 1994 created a large patient population detained at Guantanamo Bay, Cuba. This study examined the roles and results of the 59th Air Transportable Hospital (ATH) in treating surgical problems within that population during Operation Sea Signal.

METHODS

The surgical case log of the 59th ATH was used to identify all patients operated on at the 59th ATH during the interval of August 1994 to April 1995. These case records and the individual records of the three 59th ATH surgeons were used to determine the types of cases performed, complications, and outcomes.

RESULTS

A total of 333 operations were performed at the 59th ATH in three types of surgery: (1) elective (267); (2) emergency for nonself-inflicted conditions (46); and (3) emergency for self-inflicted conditions (20). The total perioperative complication rate was 2.4% (8/333), and the wound infection rate for clean surgical cases was 0.87% (2/229).

CONCLUSIONS

Elective surgery may be performed in a field environment with acceptable complication and wound infection rates. Humanitarian missions will be faced with considerable pathology from pre-existing conditions within the population cared for. The humanitarian mission may be complicated by political situations that may encourage malingering and self-injurious behavior within the population cared for. The latter events have not been previously encountered in humanitarian missions involving the U.S. military and must be considered by policy makers and mission planners in planning future humanitarian missions.

The Evolution Of Casualty Evacuation In The 20th Century (Part 5) - Into The Future

This is the final part of a series of papers that review the evolution of the military casualty evacuation system in the 20th Century. This paper draws together the themes that have been presented in the previous papers to describe the mandatory functions of such a system. The forward surgical hospital is the key treatment node if wounded soldiers are to have the maximum chance of survival. Suggestions are made for the minimum size, organisation and clinical capability of such a military medical unit. However, the majority of military casualties are likely to be less seriously injured or non-trauma cases. The casualty evacuation system must also have sufficient capacity to accommodate these patients.

Desert theatre rats

We are pleased to bring you this fascinating insight, from three theatre nurses, into life in a 200-bedded field hospital in Iraq. In February 2003 NATN members Jane Carey-Harris, a major in the Territorial Army, Mandy Coombs, a captain in the Territorial Army, and Pauline Neilson, a captain in the regular Army, were all called up. They tell us some of their story.

New horizons for OR nurses--lessons learned from the World Trade Center attack

The terrorist attacks of Sept 11, 2001, we a horrifying wake-up call for the United States and the rest of the world. The attacks led to the deployment of the disaster medical assistance team (DMAT) from Massachusetts General Hospital in Boston. In this article, members of the team outline what they did during the days after Sept 11 and the lessons they brought back to better prepare their DMAT for the next disaster.

The AMSUS History of Military Medicine Essay Award. The story of the mobile army surgical hospital[corrected]

The critical task of the physician uniting effective surgical intervention within close proximity to the front lines, and therefore the wounded, must be matched with the challenge of not becoming a casualty as well. The U.S. Army Medical Services during the Korean War balanced the surgeon's ability to protect himself and save others. This article tells the story of perhaps one of the most characteristically highlighted medical aspects of the Korean War, the Mobile Army Surgical Hospital. Originally intended to be close to the front lines of fighting, the Mobile Army Surgical Hospital was equipped to move on its own. Initially, the unit was formed to provide surgical capabilities for one division. It transformed through the course of the war into a multidivision and multinational all-purpose hospital. With this expansion in workload (medical cases in addition to surgery) without an equitable increase in personnel, rapid evacuation of patients was the only means of keeping up.

Improved anesthesia support of the forward surgical team: a proposed combination of drawover anesthesia and the life support for trauma and transport

The Ohmeda Portable Anesthesia Complete is the apparatus available for delivery of general anesthesia in the forward surgical teams in the U.S. Army. The Life Support for Trauma and Transport is being field tested for use as a single patient critical care transport bed. An effective circuit was created which linked the currently fielded draw-over anesthesia machine with the patient ventilator (Impact 754 Eagle) mounted in the Life Support for Trauma and Transport, with bench testing indicating that the anesthesia levels were accurate and that it was a useful system for field resuscitation and surgery. Others should be able to utilize this information for the benefit of their patients in field environments, especially forward surgical teams and others working in austere health care locations.