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Observer
Observer
November 12, 2014 12:51 pm

TD, so what happens now, when Camp Bastion is no more? Has the standard of medical care still improved? Or has all that improvement flown back to their respective countries?

I’m not complaining about the lives saved, I’m just pointing out that in the end, unless there were trained staff and equipment left behind, the “improvement” is only temporary.

Nick
Nick
November 12, 2014 1:03 pm

Since the NHS was pretty poor (that might be an overstatement) – I would say is, but that might be unfair – at sharing best practices between hospitals and trusts, I would be surprised that much, beyond the additional skills and experience learned by the individual medical staff, has been transferred to the NHS at all.

One would hope that the specific organizational lessons learned would be retained via the MoD’s institutional knowledge base for next time though. However, things like staff knowledge and experience (eg finding surgeons experienced in ballistic trauma injury surgery) might be somewhat transferable at a theoretical level via military medical training regime.

monkey
monkey
November 12, 2014 1:20 pm

IIRC we use to dispatch medical staff to hots spots around the world to keep their skills current or start the process I assume this will restart. Certain hospitals in the US A&E units were good for regular intakes of gun shot wounds but there are more than enough war zones for our staff to keep current and lend a needed hand.

a
a
November 12, 2014 1:32 pm

IIRC we use to dispatch medical staff to hot spots around the world to keep their skills current or start the process I assume this will restart.

The Royal London Hospital, which sees more GSW* than any other UK hospital, was used as well – not now, because they dug their heels in about trainee military medics seeing civi patients.

(*That’s still not very many GSW; there was talk about using Port Elizabeth in South Africa to train medics, which has a hell of a lot more, but I think that fell through.)

Jonathan
Jonathan
November 12, 2014 2:31 pm

That’s a lot of trauma cases.

How do the armed forces keep a cohort of trauma teams with expertise in treating GSW and blast injuries available for deployment ?

The NHS cannot provide medical professionals with this expertise, as most clinical staff working in NHS trauma centers will never see a single GSW let alone blast injuries ( it’s all RTCs, stabbings and falls)

When you are talking about the effective mamangement of trauma patients the number of cases you see counts, to stay at the top of their game clinicians need to reguarly participate in actual cases.

I would say the only way is to regularly ( as in once a year) deploy forces medical staff to centers where they will see GSW trauma. That’s trauma centers in the states and South Africa.

As for keeping up skills in treating blast injuries, I have no idea other than practicing in an active war zone.

So the lessons learn around trauma management in a war zone can be put in a book and passed on in classrooms. The big life savers are the skills of the trauma teams themselves, theses would have developed through actual practice and managing these patients and will be lost in time.

Phil
November 12, 2014 7:21 pm

The thing to remember with trauma patients is that its all physiology stupid.

The biggest lessons that have been learned have been theoretical – the importance of arresting catastrophic haemorrhage before worrying about airway, the best make up of a trauma team, the need to sometimes bypass the trauma bay and go straight into surgery, use of recombinant factor VIIa, taking shock packs forward in the MERT etc

In other words resuscitation has become far more aggressive but it still uses, by and large, the same skill-sets you’d use for a lot of other procedures and interventions.

As long as clinicians are being exposed to patients and some degree of trauma we’ll forget less than you think. Of course there’ll be some loss of experience in managing the worst trauma cases and nothing can make up for 6 months of dealing with that level of trauma on a day to day basis but the BATLs manuals and CGOs have encompassed all the major lessons learned. Most of the lessons learned simply take interventions and skills used in many other procedures and situations.

The counter-argument of course is that all that focus on trauma will have reduced exposure to medical emergencies – like Ebola or a CBRNE incident.

tweckyspat
November 12, 2014 7:41 pm

What lessons learnt ? There is also the less welcome thought that UK Def Med Svcs could not deliver this kind of level of trauma care in any much higher intensity operation…. we simply wouldn’t have the luxury of enought MERTs and surgeons to go around.

So we have potentially acclimated (as the sceptics might say) our soldiery to a level of med support that most likely can’t possibly be expected in higher intensity fighting… and it’s not just a UK problem because it also applies to all the non US NATO elements in ISAF

So I don’t think this one is going away. …

Phil
November 12, 2014 7:57 pm

What lessons learnt? I can show you a BATLs manual from 2000 and one from 2010 – the differences are clear, stark and life saving.

So we have potentially acclimated (as the sceptics might say) our soldiery to a level of med support that most likely can’t possibly be expected in higher intensity fighting

Not really. Everyone was very realistic about the med capabilities in Afghan which were often saturated at the local level. It wasn’t something taken for granted in my experience, on the ground.

tweckyspat
November 13, 2014 4:02 am

Phil I hope you are right and you clearly know a bit about the situation from the sharp end. From a long term capability planning angle I just see expectations rising from all quarters that soldiers can expect to survive unbelievably severe traumatic injuries; but (as you know) the reality is we could only ever aim to meet this rising expectation for small scale and lower intensity operations. Or we seriously rethink the Role 3 and medevac (or whatever called this week) scaling more larger scale operations, which I don’t see any appetite for from a resource perspective

Kevin R.C. O'Brien
Kevin R.C. O'Brien
November 13, 2014 4:20 am

One thing worth remembering is that even over here in the USA we don’t have the luxury of training everybody in, say, the public hospital in Detroit.

We do have reserve and National Guard medical units and individual physicians. One surgeon (who actually sent me on a medevac journey) was a very experienced chest-cracker from Bellevue in New York and probably had more GSW experience than any of the docs in Afghanistan at that time (over 10 years ago, mind… it was a less intensive war).

Another thing we do well is live tissue training. It is constantly a battle with fuzzy-thinking fuzzy-animal-rights moonbats to keep LTT in the program, but you really don’t want to be the first actual arterial bleed a combat medic has seen, if there’s a realistic way to train him up on laboratory animals.

a
a
November 13, 2014 10:13 am

Or we seriously rethink the Role 3 and medevac (or whatever called this week) scaling more larger scale operations, which I don’t see any appetite for from a resource perspective

True. But then, devil’s advocate, I don’t see much appetite for larger-scale operations full stop at the moment. If political and senior rank thinking changes to the point where we are seriously considering “Afghanistan, but division-level” – to take one example – then so much will have changed that stepping up med provision may be comparatively easy.

Phil
November 13, 2014 4:50 pm

Twecky

The best medical care is that given closest to the point of wounding. An NPA and some direct pressure applied 30 seconds after being hit is often worth more than a MERT. As I tried to teach people when I trained, basic things done well save lives. Treating trauma is really simple, and it’s made simpler by the kit the individual has and the team medics have. You’d always see people over-complicate a trauma moulage – it was really hard to teach them to KISS.

The evidence backs this up, the leading cause of preventable battlefield death is bleeding out. Your average soldier on patrol has the medical kit and training to deal with this in a lot of cases either through self-aid or buddy-aid.

Before 2010 a lot of Ops were being done outside the MERT bubble – the MERT bubble disappeared in most cases with the contraction of the AO but during my first tour things worked as they would have done in WWIII but the difference was the blokes had pressure dressings and CATs and the Team Medics had airways and haemostatic agents and were trained to deal with chest trauma.

The Other Chris
November 13, 2014 7:00 pm

When we see new kit in the media such as the below, is that the kind of trauma equipment that can prove useful?

http://www.popsci.com/article/technology/how-simple-new-invention-seals-gunshot-wound-15-seconds

Phil
November 13, 2014 7:11 pm

That device. I’ve not seen it used, and I don’t know what others think of it but I’m not convinced by it.

The actual haemostatic agent they use on the sponges (chitosan) has been in medical kits for almost a decade now. The challenge is getting that agent into direct contact with the bleeding. There’s various powders, ribbons and patches of various shapes and sizes on the market.

This bit of kit looks like it might be useful in a dressing station / MERT as part of a suite of haemostatic agent applicators but its a specialist applicator for a patrol medic / team medic. I didn’t treat a casualty where that applicator would have been useful. The ribbon we used (celox) was effective because you can poke it into the various bits of flesh and pack it in tight with a pressure dressing. When someone has lost both their legs what you need is huge amounts of the ribbon, not an applicator like this. Also most GSWs are quite small and I can’t see how you’d get them in the wound.

The big trauma holy grail now is non-compressible haemorrhage control. In other words internal bleeding in the torso. It can’t be compressed and has in the past only been controllable in surgery but there are some new pneumatic tourniquets that apply pressure to major blood vessels in the torso and makes the potential space available for bleeding into smaller. But it’s not a bit of kit you’d likely see team medics carrying.

Jonathan
Jonathan
November 13, 2014 9:17 pm

I’m with Phil, that bit of kit looks a bit off, I can imagine f@&king up the application under pressure and having a hole full if bits of sponge doing sweet nothing.

KISS……..pack with ribbon gauze (if you can) or just a big pressure dressing for big wounds, apply direct manual pressure, keep applying pressure and don’t get sucked into having a peek (or letting random others have a quick look) and breaking your clot, Two 16 gauge grays in the cephalic veins and step on the ringers lactate. Go directly to definitive treatment (trauma room, theatres) don’t stop applying pressure till the trauma leader or consultant surgeon tells you to ( confirm this instruction while looking them in the eye).

Phil I noted your bit about going strait to C in military trauma, that’s interesting as civilian trauma training still follows a primary survey based on ABCDE (I believe). Is that the biggest difference between battle field trauma and other types ? I have only ever seen one trauma patient bleed out and arrest, but lots of patients with compromised airways, flail chests and tension pneumothorax all of which were immediate threats to life, so my experience is that the ABCDE primary survey works well in civilian trauma rooms.

Phil
November 13, 2014 10:24 pm

Yes I’d say it was. ABC has been the big change. Its based on the evidence that exsanguination was the biggest cause of preventable death on the battlefield. And I think that’s important because it’s an algorithm thats contextualised to the mechanism of injury you find the most on any battlefield – blast. I don’t think its as relevant in civilian practice as you state. Even if you do come across catastrophic haemorrhage in civilian life it tends to be internal and hence uncompressible. Chest is the next big thing to go wrong which is why needle decompression is a team medic skill.

When you reach a triple amputee though it leaves you in no doubt as to why military algorithms have a “big C” at the start. They’ll already be hypovolemic when they land. Throw in a mashed mouth and you start to sweat.

Observer
Observer
November 14, 2014 1:19 pm

Now that is one of the reasons I hang out on TD. I’ll have to feed that back to medical. CAB, not ABC.

Dunservin
Dunservin
November 14, 2014 2:17 pm

wirralpete’s question about the need for a Bay class RFA to support MCMVs in the Gulf was mostly anwered here:

https://www.thinkdefence.co.uk/2014/11/maritime-patrol-alternatives-maritime-patrol-aircraft/#comment-312918.

Here’s yet another reason from an article published on the Navy News website today:

https://navynews.co.uk/archive/news/item/11875

Gory test for RN minehunter crews in casualty exercise

“…The Royal Navy’s input to the International Mine Counter-Measures Exercise (IMCMEX) is second only to the US Navy’s, with the bulk of the UK’s naval presence committed to the two-week-long workout, which draws to a close later this week. This year’s exercise is bigger and more varied than ever, involving more than 6,500 military personnel and 38 ships from 44 nations, with the exercise spread from the Red Sea to the Gulf of Oman and into the Gulf itself…

With a crew of just 45, HMS Penzance does not have its own doctor or full-time medic, so the ship’s coxswain, who heads up the mine clearance dive team, doubles up as the head medic, assisted by a team of fellow divers, plus chefs and stewards, who’ve received first-aid training.

“All the sailors aboard have been trained in basic first aid and we supplement that with advanced training for the ship’s medics, but it was clear from the outset that the casualties needed more than putting into the recovery position or a triangular bandage!” said Petty Officer Day.

Mine Clearance Diver Luke Scally, who was helping him, added:

“The opportunity to work with Amputees in Action provided a level of realistic training I’ve never experienced before. The actors were great guys and threw themselves into the role. Despite the alarms, the screaming and the ‘blood’ everywhere, I and the rest of the medics aboard kept cool, proving that our training really does work.”

The part-time medics on Penzance realised the casualties need more specialist treatment – provided by RFA Cardigan Bay, five miles away. The ship was built to support Royal Marines’ amphibious operations, but more recently she’s served as the command and mother ship for the Royal Navy’s four minehunters permanently stationed in Bahrain. She sent her two-man ‘medical in transit care’ team to HMS Penzance by speed boat, tasked with preparing the casualties for the transfer from the minehunter to hospital…

The casualties were first assessed by teams up to ten-strong deciding which order treatment should be given by the Royal Navy, Army and RAF surgeons, anaesthetists, nurses and medics in Cardigan Bay’s hospital facilities; a patient who has lost a leg, for example, goes straight into surgery to try to save as much of the remaining limb as possible…

a
a
November 14, 2014 2:28 pm

“I’ll have to feed that back to medical. CAB, not ABC.”

Well, to be precise it’s C-ABC . Catastrophic bleed, airway, breathing, circulation. It’s only cat bleeds (eg amputations) that take precedence over airway. Other bleeds wait until you’ve done A and B, just as before.

It’s also one of only two things that you’re supposed to do to a casualty under fire: CAT tourniquet on, roll them over to allow postural clearing of the airway, and that’s it. Everything else has to wait until you win the firefight.

Phil
November 14, 2014 4:58 pm

Yes big ‘c’ first then little c. You don’t want to be dressing normal wounds of your patient has no airway. Like wise there’s no point having an airway if your circulating volume is on the floor. You can only replace so much blood with fluid before you’re on a loser.

I find in civvy street it never hurts to say “big c” in your head and have a glance first. That way you train your mind to think automatically which helps when you’re flapping like ten men.