Ryan’s Ballistic Trauma docx

DMCC RAMC V Emergency Surgery and Major Trauma Nottingham University NHS Trust Nottingham UK and Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine Bir

DMCC RAMC (V)

Emergency Surgery and Major Trauma

Nottingham University NHS Trust

Nottingham

UK

and

Academic Department of Military

Surgery and Trauma, Royal Centre

for Defence Medicine

Birmingham

UK

Mark J Midwinter, BMedSci (Hons),

MB, BS, Dip App Stats, MD,

FRCS (Eng), FRCS (Gen)

Academic Department of Military

Surgery and Trauma, Royal Centre for

Defence Medicine, University Hospital

Birmingham

UK

Peter F Mahoney, OBE, TD,

MSc FRCA L/RAMC

Defence Professor Anaesthesia

and Critical Care

Royal Centre for Defence Medicine

Birmingham

UK

FRCSEd (Orth), FIMC RCSEd, DMCCAcademic Department of Military Surgery and Trauma

Frimley Park Foundation TrustFrimley, Surrey

UKTimothy J Hodgetts, CBE, MMEd, MBA, CMgr, FRCP, FRCSEd, FCEM, FIMC RCSEd, FIHM, FCMI, FRGS L/RAMCAcademic Department of Military Emergency Medicine

Royal Centre for Defence MedicineVincent Drive, Edgbaston Birmingham Research Park Birmingham

UK

Associate Editor

John-Joe Reilly, BSc (Hons), GIBiol, PhD,

DIC, BMedSci (Hons), BM, BS

Academic Department of Military Surgery

and Trauma, Royal Centre for Defence

Medicine, University Hospital

Birmingham

UK

First edition, Ballistic Trauma: Clinical Relevance in Peace and War (0340581144), published by Arnold, 1997.

DOI 10.1007/978-1-84882-124-8

Springer London Dordrecht Heidelberg New York

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Control Number: 2011922047

© Springer-Verlag London Limited 2011

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This book is dedicated to John Pryor, trauma surgeon, mentor and friend.

John died in a rocket attack during his second tour of duty as a Combat Surgeon in Iraq on Christmas Day 2008.

He is missed.

Adam J Brooks

This Preface is being written at the joint UK–US Hospital in Helmand Province, Southern Afghanistan

Over the last few weeks the Hospital has received casualties from gunshot, burns, mines and improvised explosive devices (IEDs). Adults, children, soldiers and civilians have all been received and cared for according to clinical need

The lessons from the third edition of Ballistic Trauma are being used here on a daily basis. The third edition represents a blend of experience, best evidence and cutting edge scientific research from DSTL. The Royal Centre for Defence Medicine is a focal point where the three strands are blended and turned into practical guidance

We hope that readers working in similar (and less extreme) circumstances will find the book helpful and to the benefit of all their patients

Adam J. BrooksPeter F. Mahoney

Why this book, why now?

In  1997  Prof  JM  Ryan  and  others  produced  the  reference  work  “Ballistic  Trauma: Clinical Relevance in Peace and War” (Arnold 1997). Much of this is still valid but a num-ber of concepts in care of the ballistic casualty have changed. These include developing ideas  on  fluid  resuscitation  and  refinement  of  field  protocols  based  on  operational experience

Authors, editors and colleagues expressed the view that there was a need for a practical guide  encompassing  these  developments,  along  the  lines  of  Conflict  and  Catastrophe Medicine (Springer 2002). The aim was to distill ‘real life’ practice and try to capture that which is often lost or diluted in traditional texts

Then  with  “9/11”  the  world  changed.  Since  then  major  conflicts  have  occurred  in Afghanistan and Iraq and operations are still on going. Many of the authors and editors deployed to these conflicts with NGOs, Aid Agencies and the military

Others are working with these injuries on a day to day basis at one of the USA’s busiest trauma centres

This has delayed the production of “Ballistic Trauma-a practical guide” but means that people are writing with recent experience of managing ballistic injury. Colleagues return-ing from deployment have emphasised the need for clear guidance on managing ballistic injury, especially as more and more military reservists are being deployed and their day to day work may not include managing these types of injury

Authors have been given a relatively free hand in structuring their chapters so they would be unconstrained by the book’s style and able to pass on their lessons unhindered.Finally our request is that this be a “living” document. Give us feedback. Record what treatment works and what doesn’t. Use this knowledge to improve the care of the ballistic casualty

 James M. Ryan

C. William Schwab

Ballistic Trauma: Clinical Relevance in Peace and War

This book aims to bring together the science behind and the management of ballistic trauma. It is directed at the surgeon, though perhaps not an expert, who might find him or herself having to deal with patients suffering from penetrating trauma in environments as diffuse as a late twentieth-century hospital or the arduous conditions of a battlefield.The also brings together the views of UK and US experts from military and civilian backgrounds. This composite view was deliberate as it was recognized that these poten-tially diverse views reflected the complexity of an international problem that increasingly impinges on the practice of surgery in today’s world

The UK editors were the joint professors of military surgery to the three armed services and the Royal College of Surgeons of England along with a medical scientist with an inter-national reputation in the field of ballistic science. The US editor is professor and chairman 

of the Department of Surgery at the Uniformed Services University of the health Sciences and has extensive experience in the management of ballistic trauma

Though  the  book  is  heavily  influenced  by  the  military  background  of  many  of  the authors, it is directed at a much wider audience, particularly those who may unexpectedly have to deal with the consequences of the trauma seen in an urban environment. It com-pares and contrasts the differing civil and military management viewpoints and goes on, where relevant, to debate the areas of controversy in the specialized fields of the relevant authors

The subject of ballistic trauma is controversial in part because its management depends 

derstanding that emanates from the failure to recognize that the location of surgical facili-ties, the numbers of injured and whether the injuries are sustained during peace or war may have a profound effect on the way patients are treated. The lesson of history is that you cannot take the experience of an urban hospital on to the battlefield. It can also be said that you cannot do the reverse and nowadays there is further confusion from the deployment of troops to “peace-keeping” duties performed under the scrutiny of the media. The latter is not the same as war

so much upon the situation in which it occurs. There is thus often confusion and a misun-The book has four sections: the first is on the science behind understanding ballistic trauma; it also adds to its declared remit by including a chapter on blast injury; a second section is on general principles of assessment and initial management; a third section deals with management from a regional perspective; the fourth section is on more specific but general  problems.  The  intention  is  to  provide  surgeons  with  an  understanding  of  the 

The  book  acknowledges  that  no  single  viewpoint  can  address  the  management  of patients sustaining ballistic injuries and does not fall into the trap of recommending rigid and single guides unless there is a convergence of opinion. Its approach has been to pro-vide a greater understanding so that the clinician facing the clinical problem feels suffi-ciently informed as to make coherent choices appropriate to the circumstances

James M. RyanN.M. RichR.F. DaleB.T. MorgansG.J. Cooper

Illustrations provided by Corporal Anthony W. Green

Corporal  Green  studied  Art  at  North  Oxfordshire  College  of  Art  and  Design,  after which he studied Journalism at University of Derby. He has written a number of books including the history of his own Territorial Army medical unit entitled “A Jolly Good Show”. He has served with the Territorial Army for 10 years. This service has included tours in both Iraq and Afghanistan

All illustrations contained within this book were made while he was serving with the 

UK JF Med Group Role 3 Hospital at Camp Bastion on 2009

Jillian Staruch is a student at The Pennsylvania State University. She will graduate with 

an Architectural degree in 2012. As the youngest of five, she enjoys spending time with her family and freelances in graphic design

Figure 18.3 and 28.2 drawn by Dan Miller. He works as a freelance graphic artist in the UK

Part II Weapons, Blast and Ballistics

4 How Guns Work    23

11 Ballistic Protection    125

Alan Hepper, Daniel Longhurst, Graham Cooper, and Philip Gotts 

12 Forensic Aspects of Ballistic Injury    149

Jeanine Vellema and Hendrik Scholtz 

Part III Trauma Systems

13 Civilian Trauma Systems   179

Part VI Clinical Care

23 Damage Control Surgery: Concepts    317

36 Ballistic Trauma in Pregnancy    549

Michael J. Socher and Peter E. Nielsen  

37 Managing Ballistic Injury in the NGO Environment    561

Ari K. Leppäniemi  

Part VII Critical Care

38 Critical Care for Ballistic Trauma in Austere Environments    585

Part VIII Reconstruction and Rehabilitation

43 Role 4 and Reconstruction    657

Steven L.A. Jeffery and Keith Porter  

44 Conflict Rehabilitation   669

John Etherington 

Part IX And Finally

45 Have You Read MASH?    693

Peter F. Mahoney 

Index    699

Academic Department of Military Surgery and Trauma, Royal Centre  for Defence Medicine,  

Birmingham, UK

Kate Brown, MA, BM, BCh MRCS (lon), DipSEM

Trauma and Orthopaedics,  Royal College of Defence Medicine, Birmingham, UK

Chester C Buckenmaier, III MD

Surgery Department, Anesthesiology Division, Anesthesiology,  

Uniformed Services University,  Walter Reed Army Medical Center, Washington, DC, USA

Neil Buxton, MBChB, FRCS (NeuroSurg)

Neurosurgery Department,  Walton Centre Liverpool,  Liverpool, UK

Mark Byers, MBBS, MSc, MCEM, MFSEM, MRCGP

Ministry of Defence, Longlands, Lees Hill,  Brampton, UK 

Jon Clasper, MBA, DPhil,

and Division of Neurosurgery,  

Uniformed Services University of the Health Sciences, Bethesda, MD, USA

John Etherington, MB, ChB, MSc, FFSEM (UK), FRCP

Defence Medical Rehabilitation Centre, Headley Court, Epsom, Surrey, UK

Philip Gotts, BSc

Formerly Defence Clothing, Research  and Project Support, Defence Logistics Organisation now Ordnance Test Solutions, Ridsdale, Hexham Northumberland, UK

Jennifer Gray, BSc (Hons)

Nutrition and Dietetic Department, Warrington and Halton NHS  Foundation Trust, Warrington, UK

Ian Greaves, L/RAMC, MB, ChB, FRCP, FCEM, FIMC RCSEd, DipMedEd, DMCC, DTM&H, MIHM

Emergency Department, James Cook University Hospital Middlesborough, Middlesborough, UK

Stuart Harrisson, MB, BS, MRCS

Academic Department of Military  Surgery and Trauma, Royal Centre  for Defence Medicine,  

Birmingham, UK

Alan Hepper, OBE, BEng, CEng, FIMechE, MRAeS, ACGI

Biomedical Sciences, Defence Science  and Technology Laboratory,  

Porton Down, Salisbury, Wiltshire, UK

Damian Douglas Keene, MB, ChB, BMedSc (Hons)

Anaesthetics Department, Defence Medical Services, Anaesthetics and Intensive Care, University Hospitals Birmingham, Birmingham, UK

Emrys Kirkman, PhD

Biomedical Sciences, Defence Science  and Technology Laboratory,  

Porton Down, Salisbury,  Wiltshire, UK

Ari K Leppäniemi, MD, PhD

Department of Surgery, Emergency Surgery Division, Helsinki University, Meilahti Hospital, Helsinki, Finland

Geoffrey S.F Ling, MD, PhD

Medical Corps, US Army,  University of the Health Sciences,  

TX, USA

Peter F Mahoney, OBE, TD, MSc FRCA L/RAMC

Defence Professor Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK

Mark J Midwinter, BMedSci (Hons),

MB, BS, Dip App Stats, MD,

Intensive Care, University Hospital Birmingham, Birmingham, UK

Piers R.J Page, MBBS

Department of Orthopaedics  and Trauma, Frimley Park Hospital, Frimley, Surrey, UK

Graeme Pitcher, MBBCh, FCS (SA)

General Surgery Department,  Division of Pediatric Surgery,  University of Iowa Hospitals and Clinics, Iowa, IA, USA

Sir Keith Porter, MBBS, FRCSEng, FRCSEd, FIMC RCSEd, FCEM, FSSEM, FRSA

Royal Centre for Defence Medicine, Trauma and Orthopedic Surgery, University Hospitals Birmingham, Birmingham, UK

Susan Price, BSc (Hons), M.Sc.  

Nutrition and Dietetic Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

John P Pryor † , MD

Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, PA, USA

John-Joe Reilly, BSc (Hons), GIBiol, PhD, DIC, BMedSci (Hons), BM, BS

Academic Department of Military  Surgery and Trauma, Royal Centre  for Defence Medicine, University Hospital  Birmingham, UK

Patrick M Reilly, MD, FACS

Department of Surgery, Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania School 

of Medicine, Philadelphia,  PA, USA

Rob Russell, MB, BS, MRCP (UK),

FCEM, DipIMC RCSEd

Kerry Starkey, PhD, RAMC

Academic Department of Military Emergency Medicine,  

Institute of Research and Development, Royal Centre for Defence Medicine, Edgbaston, Birmingham, UK

Christian B Swift, MAJ AN ARNP MSN ACNP-BC FNP-BC

Internal Medicine Division, Department of Medicine, Madigan Army Medical Center, Tacoma, WA, USA

Nigel Tai, MBBS, MS, FRCS (Gen Surg)

Academic Department of Military Surgery and Trauma, Trauma Clinical Academic Unit, Royal Centre for Defence Medicine, Royal London Hospital, London, UK

Robert D Tipping, MB, BS, FRCA, RAF

Department of Anaesthetics and  Critical Care, Royal Centre for Defence Medicine, Birmingham, UK

Jeanine Vellema, MBBCh, FCPath

Division of Forensic Medicine,  School of Pathology, University of  the Witwatersrand, Johannesburg,  South Africa

Jonathan Vollam, BA (Hons) Adult Nursing PMRAFNS

Critical Care Air Support Team,  Tactical Medical Wing, Royal Air  Force Lyncham, Chippenham,  Wiltshire, UK

Sarah Watts, PhD, B.VET.MED

Biomedical Sciences, Defence Science  and Technology Laboratory,  

Porton Down, Salisbury Wiltshire, UK

Part I Personal Views

A.J Brooks et al (eds.), Ryan’s Ballistic Trauma,

DOI: 10.1007/978-1-84882-124-8_1, © Springer-Verlag London Limited 2011

of mass armed force combat at close quarters seemed to be diminishing and that the greater risk of ballistic injury was within civil society, particularly in the United States In the Preface to the first edition the editors noted: “The lesson of history is that you cannot take the experience of an urban hospital onto the battlefield It can also be said that you cannot do the reverse, and nowadays there is further confusion from the deployment of troops to peacekeeping duties performed under the scrutiny of the media The latter is not the same as war.” The events of the following decade have called these beliefs into ques-tion None could have foreseen the world shaking events that were to occur during the opening years of the twenty-first century – the terrorist attacks in the United States on

9 September 2001, the invasion of Afghanistan the same year by a US led coalition, the invasion of Iraq by a US led coalition in 2003, terrorist bombings in Madrid in 2004, ter-rorist bombings in London in July 2005, and countless other terrorist and insurgency events on every continent It is sobering to visit Wikipedia and to note the seemingly end-less list of terrorist events recorded for the period 1982–2009 War and terror have come

to our streets, towns, and cities causing civilian urban hospitals to take on the mantle of field hospitals in war

J.M Ryan

Conflict and Catastrophe Medicine, Cardiac, Thoracic and Vascular Sciences,

St George’s University of London, London, UK

e-mail: jryan@sgul.ac.uk

1.2

Changing Patterns in War and Conflict

It is useful to start by reproducing a few paragraphs from an article this author wrote on the 25th anniversary of the 1982 Falklands war It gives a sense of a war that had more in com-mon with those of the late nineteenth and early twentieth centuries but also hinted at the change that was taking place in the conduct of war

….It is strange to look back over a quarter of a century to a war that we never anticipated

In 1982 the Cold War still occupied our thoughts – and planning The RAMC were cised for a major conventional, and possibly a nuclear and chemical war, in Europe All worked to a strict military doctrine, which defined how medical support would unfold and was based around mass casualties and numerous huge Field and General Hospitals There was little flexibility in our thinking Principles of War Courses, run annually, were run by the book Directors and Professors of Military Medicine and Surgery would baulk no dis-cussions These courses were exercises in Doctrine and debate was not encouraged This author remembers discussion concerning Field Hospital with upwards of 600 beds – unheard of today Doctrine defined what would be attempted at each Role – then called echelons Mortality would have been appalling and the approach would have been “the most for the most,” hoping to get as many as possible home to UK based hospitals using all means including cross channel ferries

exer-What was faced in 1982 was unexpected and appeared to be outside planning This was the first campaign of what would become the norm – expeditionary warfare with new doctrines and new methods of working – and new expectations Mrs Thatcher’s statement in the House of Commons some years later that wounded soldiers in war would get the same treatment as the injured in NHS hospitals had not yet been voiced The first Gulf war was undreamt of and later expeditionary wars in the Balkans, Iraq and Afghanistan beyond our wildest imagination ….1

Until the last quarter of the twentieth century many viewed war as a set piece activity between two massed armies facing each other in the field to do battle with rifle, machine gun, and artillery– in a word - symmetric warfare The war in the Falklands in 1982 was such a war, although on a small scale The massed armies of the American civil war and World War I also come to mind Of course this view is quite wrong and risks viewing war through rose colored spectacles In fact the nature of war had begun to change with the pace accelerating in the early twentieth century with advent of air warfare and stra-tegic bombing of cities Harris, who conducted strategic bombing between 1939 and

1945 in Northern Europe, had used aerial bombardment in Kurdistan in the 1920s The Luftwaffe advanced further this method of warfare during the Spanish civil war – the destruction of Guernica in April 1937 was a watershed and pointed to what would follow

in the decades ahead The later destruction of German and Japanese cities, the carpet bombing of Vietnam and Cambodia put paid to any illusion that war was an event to be fought by standing armies in the field with sparing of the civilian population We have now reached a point where military casualties, although appalling, pale when the civil-ian cost is considered Prior to World War I military casualties far exceeded civilian losses – some reports suggest an 80% to 20% ratio That ratio has now reversed Key observations on changes in warfare are summarised in Table 1.1

Factor Examples from History

1 General Health

and Disease In many campaigns the losses through illness have exceeded those

from enemy action Many examples

of disease adversely affecting an army can be found throughout history, often related to the conditions in which the war or campaign was being waged

The pre-existing level of fitness, nutrition, hydration, health and hygiene or disease will influence the extent to which a soldier is able

to mount an effective physiologic response to a wound, this may be markedly different in the civilian setting compared with that of war

1795 - Former Director General

of the Army Medical Department, James McGrigor (regimental surgeon), was on Abercrombie’s expedition to fight the French

in the Caribbean He reported those dying from yellow fever outnumbered four-fold those who fell from bullet or bayonet wounds

1806 - James McGrigor joined

the British expeditionary forces

in the Netherlands which was decimated by malaria, typhus and dysentery Less than 1 per cent died of wounds sustained

in action on that campaign but

10 per cent died of fever

2 Wound

contamination The conditions may influence the degree of contamination in a

wound Wounds inflicted on

a soldier on the battlefield may differ in both contamination and severity from a wound sustained from the same weapon in a civilian setting

1899 – 1902 - South Africa,

fighting occurred on the veld in

a hot, dry climate Uniforms were made of lightweight materials and wounds had little material carried in; soil contamination was minimal

1914 – 1918 - Flanders Heavy

clothing covered in manure from the fields meant soldier’s wounds were deeply contaminated

3 The range that

forces engage

one another

The exact nature of the campaign can alter the severity of wounds inflicted

18 th – 19 th Century - The effective

range of the musket was about

100 – 200m, so forces front lines tended to separate at this distance

1899 – 1900 - South African War

This conflict was characterised by rifle fire ranges beyond 500m in many instances with sniping at even greater distances

1914–1918 - In comparison, in

the early stages of the 1st World War rifle engagements were at much closer range than in South Africa, though with similar weapons; bullet wounds were reported as far more severe

in WW1

(continued)

Table 1.1 What can influence the way wars are fought and the wounds that result?

Table 1.1 (continued)

Adapted by Starkey from Ryan et al.2

4 Overwhelming

Technology 1898 - Battle of Omdurman in the Sudan The British employed

20 Maxim machine guns and artillery pieces to devastating effect

The Sudanese lost 11000 men, the British 48

New technology is not always a guarantee of success, on many occasions guerrilla or irregular forces have defeated a techno-logically superior enemy, particularly in the low-intensity conflicts of the 20th century

1.3

War and Conflict in the Twenty-First Century

We now appear to have entered an era characterized by world wide terrorism waged by state and non-state actors and on an unprecedented scale Terrorist war is being waged on every continent Many of the terrorist groups have emerged from failed and rogue states – most notable are Taliban and Al-Qaeda and countless allied groups They have a worldwide reach

as is evident from earlier discussions The response from countries targeted by these groups, the USA and UK in particular, has been an upsurge in what is best described as expedition-ary warfare waged by invading countries and regions harboring the terrorist groups But there is a sting in the tail Iraq is an example The purpose of the invasion was to depose a despot and prevent the proliferation and use of chemical and biological weapons The result was a failed state (although now recovering) which then became a haven for the very people the expeditionary war was meant to destroy – in the case of Iraq, Al-Qaeda infiltrated the region and this led to on-going instability and asymmetric warfare The invading coalition won the symmetric battle against the Iraqi army but has yet to achieve victory in the asym-metric battles that followed and continues albeit much reduced

What does this mean for the readers of this new 3rd edition of Ballistic Trauma? The implications are many but two are paramount – the advent of asymmetric warfare carried out in the midst of civilian populations and the spiraling cost to civilian bystanders The most startling consequence is that the clear and distinct separation between trauma surgery

on the battlefield and in civilian hospitals has been blurred to point of irrelevance Civilian surgeons in Europe and North America now face wounds caused by terrorist explosions which are indistinguishable from battlefield wounds and war surgeons are being required

to treat civilians, particularly in failed and rogue states, where they may be the only tive health care providers – East Timor is a vivid recent example where humanitarian and military medical teams were faced with a population quite without any form of medical care Clearly there has been a paradigm shift in this new and globalized world of the twenty-first century Equally a radical change in outlook is needed by both civilian and military health care providers This change has particularly resonance for surgeons and their teams – it seems that both sides have, not least, new training and educational needs and this is an important driver for this new 3rd edition of Ballistic Trauma

effec-One of the most worrying problems is the changing nature of surgical training In 1982, when this author deployed to war, surgical training was long, arduous, and truly general

Most of the deployed were senior registrars and were in the final year of a training program lasting at least 10 years A further extract from the paper quoted earlier is illuminating.

…In 1982 the author was a 37 year old Senior Specialist in Surgery (in modern parlance –

a Specialist Registrar) in the sixth and final year of higher professional training programme and seconded to St Peter’s Hospital in Chertsey It is worth pausing for a moment to reflect

on this old and discarded training programme Three years of general professional training, followed by six years of higher training had resulted in exposure to the generality of sur-gery It included postings to nine separate hospitals including three NHS secondments to

St Bartholomew’s, Hackney and St Peters Hospitals with training in general, orthopaedic, plastic, neurosurgical, thoracic and vascular surgery – an unimaginable variety today All military surgeons in training at that time had very similar training programmes The aim was to produce a surgeon trained in the generality of surgery ready to work alone or in small groups in field surgical facilities This system of training probably gave the surgeons who would deploy a training edge not available to civilian trainees of the period

This was also the age before war surgery workshops, Definitive Surgical Trauma Skills (DSTS) courses and the myriad of other training opportunities, including overseas second-ments, available to today’s military surgeons and their teams Training in the art and sci-ence of war surgery prior to 1982 was not easy Military surgeons “cut their teeth” during secondments to the Military Wing, Musgrave Park hospital in Northern Ireland The

“Troubles” were in full swing and a generation of surgical trainees worked with an earlier generation of military surgery consultants such as Bill McGregor, Bill Thompson and Brian Mayes who had learnt their trade during a myriad of post colonial conflicts in far flung places like Cyprus, Aden, Malaya and Borneo There was, in short, an institutional memory for the surgery of war which would become evident as the Falkland Islands war progressed The military surgeon’s bible and almanac at that time was the latest edition of the Field Surgery Pocket book edited by Kirby and Blackburn and would become essential reading for all deployed military surgeons, irrespective of previous experience or colour of cloth…1

Clearly there were, and still are problems in training facing both groups

1.3.1

Training and Education Problems for Civilian Surgeons

Civilian surgeons and their supporting teams are now exposed (and will continue to be exposed) to battlefield ballistic and blast injuries and this exposure happens in three quite different scenarios –

Terrorist attacks on the civilian populations in our cities and while traveling in countries

•

with home grown terrorist groups – Bali in Indonesia for example

During deployments to war zones as a result of reserve service or volunteer

commit-•

ment (In the UK The Territorial Army)

During deployments as volunteers with non-governmental organizations (NGOs) in

•

conflict and disaster environments

There seem to be irreconcilable difficulties here The training environment has changed radically over the last 30 years This is, and quite rightly, the age of shorter but intense train-ing in sub-specialty fields such as colo-rectal or upper GI Further, the European Working Time Directive is striving to achieve shorter and shorter working hours resulting in one

Royal Medical College President calling the directive “sheer lunacy.” Possible solutions

will be discussed later but a personal communication with one of the editors of this 3rd edition heralds a warning He was deployed with a leading humanitarian organization

in a totally failed state – two surgeons were deployed, one orthopedic, the other a general surgeon Perhaps not quite so general! On being told by the command that there was a need

to provide a full surgical service, the general surgeon said he was a sub specialty trained,

in particular, he was not trained or prepared to operate on children In this setting – a ter in the making is hardy an understatement

disas-1.3.2

Training and Education Problems for Deployed Civil and Military Surgeons

Deployed surgeons, whether civilian or military face unique problems compared to ian counterparts working in city hospitals Deployed surgeons, while having to gain exper-tise in trauma and war surgery, are now faced with new difficulties They have to take on the mantle of the old fashioned general surgeon In the new operational environment, char-acterized by the failed state there is typically a collapse of the institutions of a functioning state, including health care As a result deployed surgical (and medical teams), military and NGO, may be the only health care providers This poses problems for all, but particu-larly for surgeons who, increasingly are trained within narrow specialty and sub-speciality fields This is leading to what an eminent colleague of this author calls “… deployed sur-geons hunting in teams.” Working in teams helps but is not always possible or feasible

civil-So in summary, we have the curious situation in which the civilian surgeon working at home has little or no trauma and war injury experience and on the other hand we are faced with a new generation of deployed military and NGO surgeons, who will probably be competent in trauma but who do not have the broad based general experience to provide care for a local population in need A curious paradox

1.4

Towards a Solution

There is no single solution to deal with these complex problems However, solutions, some

of them novel, can be found Based on this author’s own experience some or all of the lowing might be considered by prospective volunteer surgeons, depending on the likely mission

fol-1.4.1

General and Trauma Training

For civilian surgeons wishing to widen their day to day skills in general surgery and to improve their skills in trauma care there are a number of options These options might also

be useful for deployments to natural and man made disaster settings where the focus will

be on old fashioned general surgery and major trauma These include:

1.4.1.1

Visits and Attachments to Leading International Trauma Centers

Increasingly health care providers and deploying agencies are turning to secondments to busy trauma center in the USA and South Africa to expose surgeons and their teams to the skills needed to manage major trauma Johannesburg, with a very high incidence of penetrating ballistic and knife injury, is a popular destination for both civilian and mili-tary surgeons and their teams (Fig 1.1)

1.4.1.2

Courses and Workshops

Craft workshops and courses abound Some of these such as ATLS© and DSTC©/DSTS© are particularly popular and regarded by some as mandatory Most of these courses have supporting Web sites and provide details on course provision (Fig 1.2)

Fig 1.1 A UK team visiting a

trauma center in

Johannes-burg

Fig 1.2 A pre-hospital

trauma exercise in South

Africa

1.4.1.3

Secondments to Austere/Post Conflict Environments

These can be useful, particularly for civilian surgeons considering an austere overseas sion The author ran a university based conflict and catastrophe center at University College London tasked with assessing health needs in post conflict and post disaster settings While the main tasks were data gathering these missions allowed an exposure to austere environ-ments and gave useful pointers to clinical practice in a variety of post conflict and post disaster environments In this author’s view these type of mission provide a reality check for potential volunteers prior to the real thing! One of these missions was to the former Soviet republic of Azerbaijan

Azerbaijan Assessment Mission 1997–2003

Azerbaijan, a former Soviet Republic, now independent state, serves as a good case ple Although now a recovering state, in 1997 it fitted the definition of a failed state The background to the crisis in Azerbaijan can be summarized as

exam-70 years of control by the former Soviet Union

from the consequences of financial ruin and loss of social cohesion

Major teaching hospitals fared better retaining staff and supported by a growing private

•

practice

Creation of dozens of refugee and IDP camps accommodating up to one million men,

•

women, and children

Deployment to Azerbaijan of UK NHS volunteer health care professionals, particularly surgeons, anesthetists, and emergency physicians, gave an unparalleled exposure to the practice of medicine in all its generality well away from the “ivory tower” of the modern NHS and provided priceless training for future deployment (Figs 1.3 and 1.4)

Fig 1.3 Expatriate and local

surgeons operate in an Azeri

university hospital in the

capital Baku

1.4.2

War and Conflict Surgery Training

Visits or detachments to zones of conflict are not an option – these environments are not for the novice and should not be seen as opportunities for training Likewise, although secondments to major trauma center are useful they cannot reproduce the nature and range

of injuries nor the working environment It is interesting to consider what the UK Defence Medical Services do to prepare and inoculate their teams

1.4.2.1

Master – Apprentice Training

This is an on-going process in peacetime but requires two key elements – a reservoir of master war and trauma surgeons and a ready supply of materials – patients on which to practice In the period of unrest in Northern Ireland 1969–2002 and at the time of the Falklands War of 1982 there were masters and patients aplenty (Fig 1.5)

Fig 1.4 Professor

P Mahoney, mentoring

theater staff in an Azeri

hospital

Fig 1.5 The Master –

Apprentice system at work

in the Falkland Islands 1982

The Master Surgeon is the

late Colonel Bill McGreggor

Now there are few masters in war and trauma and new strategies are being tried These include.

1.4.2.2

Courses and Workshops in War and Conflict Surgery

These are run by military and humanitarian agencies The ICRC and the Defence Medical Services in UK run regular principles of war surgery courses for deployed teams Complimenting these is a series of specialist craft workshops covering maxillo-facial, neu-rosurgical, and vascular injury Two relatively recent initiatives merit further comment

Definitive Surgical Trauma Skills ©

This is a tri-partite course run jointly by the Royal College of Surgeons of England, The Royal Centre for Defence Medicine and the United Services University of the Health Sciences in Bethesda, MD, USA It is a 2 day hands on, master class cadaver based course covering abdominal, vascular, and thoracic injury with international military and civilian trauma surgeons as faculty Military and civilian students from Europe are the main par-ticipants and feed back is very positive Variants of this course are run in many countries

in the world, many using a bleeding live animal model which is forbidden in the UK

Military Field Hospital Deployment Exercises (Hospexs)

These training exercises are held in Strensall, outside York, and are aimed at collective training for field hospital staff about to deploy A modular field hospital with virtually full equipment scales and departments is used Exercise casualties, based on actual casualty data from Iraq and Afghanistan, are fed into the hospital over a 3 day period The aim is to facilitate collective team training covering all aspects of hospital activity, including com-mand and control, communication, casualty evacuation as well as clinical activity cover-ing A&E, ITU, Theater, wards, and all support functions

This environment provides a highly realistic training tool as evidenced by feed back from deployed teams Training is being enhanced by the addition of computer controlled simulators providing real time physiology and responses to interventions

in interesting and changed times As demand grows for wider skills in the deployed setting, our colleges and universities are producing ever more sub specialized hospital doctors, par-ticularly surgeons There are no easy answers – however novel solutions are being discussed and some of these are outlined in this paper It is too early to say if these will be successful – the author and editors hope this new edition will be part of the wider solution.

References

1 Ryan JM A personal reflection on the Falklands Islands War of 1982 J R Army Med Corps

2007;153:88-91

2 Ryan JM, Rich NM, Dale RF, Morgans BT, Cooper GJ Ballistic Trauma: Clinical Relevance

in Peace and War London: Hodder Arnold; 1997:18-20.

Quotes from reference 1 used with permission of the Editor J R Army Med Corps.

Fig 1.6 Troops in Helmand,

Afghanistan 2009 Cpl Tony

Green