international review of the armed forces medical services

INTERNATIONAL REVIEW OF THE ARMED FORCES MEDICAL SERVICES

REVUE INTERNATIONALE DES SERVICES DE SANTÉ DES FORCES ARMÉES

Official organ of the International Committee of Military MedicineOrgane officiel du Comité International de Médecine Militaire

INTERNATIONAL REVIEW OF THE ARMED FORCES MEDICAL SERVICES

Quarterly: March 2014 • Trimestriel : mars 2014 VOL. 87/1

Couverture1_2014_Mise en page 1 13/03/14 18:04 Page1

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International Review of the

ARMED FORCES MEDICAL SERVICESInternational Review of the

ARMED FORCES MEDICAL SERVICESRevue Internationale des Services de Santé des Forces Armées

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EDITION / REDACTION

Director / DirecteurMaj. Gen. (ret.) R. VAN HOOF (MD)[email protected]

Editor-in-Chief / Rédacteur en chefMaj. Gen. Prof. (ret.) M. MORILLON (MD)[email protected]

Assistant Chief-Editor / Rédacteur en chef adjointCol. Prof. G. THIERY (MD)[email protected]

Secretary of the Editorial BoardSecrétaire du Comité de rédactionCWO I. [email protected]

Editor’s office / Bureau de la rédactionInternational Committee of Military MedicineComité International de Médecine MilitaireHôpital Militaire Reine AstridBE-1120 Brussels (Belgium)� : +32 2264 43 48 - 6 : +32 2264 43 [email protected]

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SCIENTIFIC COMMITTEE / COMITÉ SCIENTIFIQUE

Brig. Gen. J. ALSINA (MD)(Spain / Espagne)

Col. Prof. H. BAER (MD)(Switzerland / Suisse)

Col. JJ BRAU (Dent.)(France / France)

Col. M. DEBBOUN (MD)(U.S.A. / Etats-Unis)

Col. T. S. GONZALES (Dent.)(U.S.A. / Etats-Unis)

Maj. Gen. KHALID A. ABU-AZAMAH AL-SAEDI (MD)(Saudi Arabia / Arabie Saoudite)

Col. I. KHOLIKOV (MC)(Russian Federation / Fédération de Russie)

Sen. Col. Dr C. M. LOMMER (Pharm.)(Germany / Allemagne)

Maj. V. ROUS (Vet.)(France / France)

Col. P. VAN DER MERWE (Vet.)(South Africa / Afrique du Sud)

Air Cdre. (ret.) A.J. VAN LEUSDEN (MD)(The Netherlands / Pays-Bas)

Sen. Col. Prof. L. ZHANG(China / Chine)

VOL.82/1

3International Review of the Armed Forces Medical Services Revue Internationale des Services de Santé des Forces Armées

Official organ of theInternational Committee of Military Medicine

Organe officiel duComité International de Médecine Militaire

VOL.87/1

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CONTENTS Sommaire

CONTENTSSommaire

The Role of General Medical Practitioners inthe Care of Military Veterans with Mental HealthProblems.By A. FRITH. United Kingdom.

Scorpions of Military Importance in SaudiArabia: Morphological Characteristics, ClinicalProfile and Management.By A. K. AL-ASMARY and M. DEBBOUN. Saudi Arabia

The Role of Tunisian Military Veterinariansin a Refugee Camp Close to the Libyan Border.By A. AGAL, M. JAAFAR, C. BACCARI and S. HADDAD.Tunisia

70

57

51

ORIGINAL ARTICLES / ARTICLES ORIGINAUX

Prévalence du syndrome métabolique dansune cohorte de militaire du sud tunisien.Par R. ALLANI, S. BOUOMRANI, A. MRABET, R. BELLAAJ,O. SAIDI, S. ASLI, M. BEJI et M. YEDEAS. Tunisie

Fait clinique : un éclat suspect !Par L. AIGLE, F. LIMAS, C. BAY et J. SAMY. France

Russian System for Temporary Control ofExternal Hemorrhage in Combat-related MajorExtremity Vascular Injuries: Realities and Prospects.By I. M. SAMOKHVALOV, A. N. PETROV and V. A. REVA.Russian Federation

Military Mobile Medical Team Unit Project,Fort Wachiraprakan Hospital, Tak Province, Thailand.By S. PLUNOI and C. SUBUN. Thailand

The Modus Operandi of the Module BattleStress Recovery Unit (Mod BSRU) Deployed to UNIFILfrom October 2006 until March 2009.By J. BANCKEN. Belgium

Air Evacuation of Cases of Botulism in Thailand.By P. WONGCHERNTHAM. Thailand

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12

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37

46

20

Views and opinions expressed in this Review are those of the authorsand imply no relationship to author’s official authorities policy, presentor future.

Les idées et opinions exprimées dans cette Revue sont celles des auteurs etne reflètent pas nécessairement la politique officielle, présente ou futuredes autorités dont relèvent les auteurs.

VOL.87/1


Photo on the cover: Article : Fait clinique : un éclat suspect !- Case Report: A Suspect Shrapnel ! (L. Aigle - France).

01-Sommaire_Mise en page 1 13/03/14 18:08 Page2

Par R. ALLANI❶, ❹, S. BOUOMRANI❷, A. MRABET❶, ❹, R. BELLAAJ❶, O. SAIDI❹, S. ASLI❸, M. BEJI❷ et M. YEDEAS❶. Tunisie

Riadh ALLANI

Prévalence du syndrome métabolique dansune cohorte de militaire du sud tunisien.

Lieutenant Colonel (MD) Riadh ALLANI,Chief of International Relations and Cooperation Bureau.

Office of the Surgeon General of Tunisian Armed Forces.ICMM Point of Contact for Tunisia.

Public Health and Epidemiology, Associate Professor - Faculty of Medicine of Tunis, Tunisia.Member of Epidemiology and Cardiovascular diseases Research Laboratory in Public Health NationalInstitute of Tunisia.Several publications in humanitarian and public health fields.

As previous positions:- Acting Chief of Health Support Division at the Directorate General for Military Health of Tunisia duringthe period of 2006 - 2007.- Member of National Coordinating Steering Committee of Sexual Transmitted Infections and fightingagainst AIDS during the same period.- Member of Military Coordinating Steering Committee of Sexual Transmitted Infections and fightingagainst AIDS since 2005.

Large experience in planning and conducting humanitarian missions:Deployed during several humanitarian missions in Tunisia and three times in overseas operations:1. Restore Hope / Continue Hope during UN PKO Mogadishu Somalia for 53 weeks in 1993-1994.2. Tunisian Humanitarian Mission in Albania for 8 weeks in 1999 in Tirana during the Kosovo Crisis.3. Tunisian Humanitarian Assistance Mission for 3 weeks in 2003 during Boumerdes Algeria Earthquake.

Achieved with success the Officer Advanced Course in Army Medical Department Center & School (FortSam Houston, Texas) - USA in 2002.

Decorations1. UN decoration in 1993.2. Tunisian Armed Forces Decoration in 2010.

Dr. Allani is married and father of two children.


ARTIC

LES

ARTIC

LES

SUMMARY

Prevalence of metabolic syndrome within a military cohort in southern of Tunisia.

Background: Tunisia started during the last few years a triple demographic, nutritional and epidemiological transition1-3 charac-terized by the increase in non-communicable diseases. It is related to changes in lifestyle, to improve of socio-economic statusand urbanization. Metabolic disorders represent components of the metabolic syndrome and one of cardiovascular risk factors.Their prevalence is increasing in Tunisia4. Data relating to the health of military and civilian armed personnel in this area remainscarce.Aims: To estimate the prevalence of metabolic abnormalities and metabolic syndrome within a cohort of military and civilianpersonnel practicing in southern of Tunisia armed force units.Materials and methods: cardiovascular risk factors 2008 survey conducted in Tunisian armed force southern units is a descriptivecross-sectional study conducted within a cohort of 709 male volunteers, 20 year old and more, military and civilian armed force,active duty personnel working in the south of Tunisia.Results: The prevalence of hypercholesterolemia (TC > 6.2 mmol/l) and limit cholesterol (TC: 5.2 to 6.2 mmol/l) were respectively2.1% and 9.4%. The most common individual metabolic abnormality was hypo HDL cholesterol (69.6%) followed by the waistcircumference elevation (39.1%). They varied significantly with the age group (71.4% and 44.9% among those aged 35 +) andwith BMI class (81.4% and 85% among obese).The prevalence of metabolic syndrome was 17.6% in our cohort. It varied significantly with age group (10.8% in 20-29 years,14.5% in 30-39 years and 28.2% for 40 years +, p = 0.003) but did not vary according to the military or civilly status or according

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INTRODUCTION

La Tunisie a entamé depuis quelques années une tripletransition démographique, nutritionnelle et épidémio-logique1-3 liée aux changements du mode vie, à l’amé-lioration du niveau socio-économique et à l’urbanisa-tion. Cette transition est caractérisée par l’accroissementdes maladies non transmissibles, notamment les troublesmétaboliques. Ils représentent les éléments constitutifsdu syndrome métabolique et constituent un des facteursde risque cardiovasculaires. Leurs prévalences ne cessentd’augmenter en Tunisie4.

Malgré les particularités de la population militaire,caractérisée par le jeune âge, la sélection médicale àl’incorporation et le mode de vie actif, l’armée n’est pasépargnée de ces problèmes de santé. Les maladies nontransmissibles et les facteurs de risque cardiovasculairescommencent à s’y installer et deviennent une prioritédes services de santé des armées5-9. Peu d’études se sontintéressées au syndrome métabolique en milieu mili-taire. Leurs fréquences seraient plus faibles comparéesà la population générale; toutefois leur dépistage restejustifié puisque ce milieu n’en est pas préservé10-12. Lamise en place d’une stratégie globale combinant l’ap-proche populationnelle basée sur la prévention primor-diale permettant d’éviter ou de retarder l’apparition desfacteurs de risque et l’approche à haut risque ciblant ledépistage précoce de ces facteurs et la prise en chargeénergique des sujets déjà présentant des anomaliesmétaboliques permettrait de préserver la faible prévalencedu syndrome métabolique.

L’objectif de ce travail était d’estimer la prévalence destroubles métaboliques et du syndrome métaboliquedans une cohorte de militaire exerçant dans les unitésmilitaires du sud de la Tunisie en 2008.

MATÉRIEL ET MÉTHODES

Les données de notre étude étaient extraites de l’en-quête de 2008 sur les facteurs de risque cardiovasculairedans les unités militaires du sud tunisien. Il s’agissaitd’une enquête populationnelle transversale réaliséedurant la période du 1er avril au 31 juillet 2008 auprèsd’une cohorte de 709 sujets volontaires, militaires etcivils de carrière, encore en activité et exerçant dans les

différentes unités de l’armée dans la garnison de Gabès(Sud de la Tunisie).

Le personnel enquêté appartenait à neuf unités pour laplupart des unités de soutien relevant de l’armée deterre, de l’armée de l’air et des services communs del’armée. Les sujets inclus dans l’étude étaient tous desexe masculin, âgés de 20 ans et plus et tirés par sondagealéatoire à deux degrés en tenant compte des caractéris-tiques de leurs unités d’appartenance (effectifs parunité, armée d’appartenance, catégorie de grade,tranches d’âges et tâches à charge).

Le recrutement des sujets enquêtés était fait en colla-boration avec les médecins des unités de la garnison àpartir de bases de sondage incluant tout le personnelde l’unité. Un sujet tiré au sort et refusant de prendrepart à l’étude était remplacé par un autre sujet de lamême unité, également tiré au sort et au temps quepossible de la même catégorie de grade et de la mêmetranche d’âge. Les dates de passage de l’équipe desenquêteurs étaient fixées suffisamment à l’avance encoordination avec le commandement de l’unité pourgarantir la disponibilité du personnel concerné.

Chaque participant enquêté a bénéficié d’un examenmédical comportant un interrogatoire, un examen phy-sique et un bilan biologique. L’interrogatoire précisaitentre autres, l’âge, les antécédents personnels et fami-liaux et la périodicité des activités physiques hebdoma-daires. L’examen physique comportait des mesuresanthropométriques (poids, taille, le périmètre abdomi-nal, et la taille des épaules), de la tension artérielle sys-tolique et diastolique aux deux bras après 20 minutes derepos en position assise. Le prélèvement sanguin, réaliséaprès 12 heures de jeûne, s’est intéressé à l’explorationde la glycémie, des triglycérides, du cholestérol, du HDLcholestérol, l’acide urique et la créatinine.


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❶ Direction Générale de la Santé Militaire.

❷ Service de Médecine Interne - Hôpital Militaire de Gabès.

❸ Laboratoire de biochimie - Hôpital Militaire de Gabès.

❹ Laboratoire de recherche en épidémiologie et prévention des maladiescardiovasculaires - Faculté de médecine de Tunis.

to the belonging armed force. It was higher in those who were overweight or obese (25.1%) and sedentary (25%).Conclusion: In order to be able to keep low prevalence of diabetes, HBP and some cardiovascular risk factors in military popula-tion compared to national population, it’s recommended to set up a prevention program against theses health problems takingin account military environment specificity.Metabolic syndrome begins to settle in the armed forces. It is therefore recommended to implement a program to fight againstand prevent cardiovascular risk in the military. It must control any adverse change in lifestyle and ensure to adopt a healthy dietand constant physical activity. Sometimes, a drug therapy remains the main component of this syndrome management.

MOTS-CLÉS : Epidémiologie, Prévalence, Militaires, Syndrome métabolique, Facteurs de risque cardiovasculaire,

Tunisie.KEYWORDS: Epidemiology, Prevalence, Military, Metabolic syndrome, Cardiovascular risk factors, Tunisia.


Deux médecins généralistes et deux infirmiers spéciale-ment entraînés étaient chargés de conduire l’enquête deterrain en collaboration avec le médecin de chaque unité.Un dispositif de vérification de la qualité des donnéesrecueillies était mis en place selon un planning défini etdes séances de travail étaient organisées périodiquementavec le chef du service de médecine interne de l’hôpitalmilitaire de Gabès pour cet effet. Lors de ces réunionsétaient passés en revue les différents items du question-naire en terme de codage et de qualité du recueil de don-nées. La saisie des données et leurs analyses statistiquessont assurées par le logiciel SPSS. La définition adoptéepour le syndrome métabolique13, 14 était celle du NCEP-ATPIII (National Cholestérol Education Program) et quiprécise l’existence d’au moins trois critères parmi les sui-vants : Tour de taille > 102 cm (pour les hommes),Triglycérides > 1,6 mmol/l, HDL cholestérol < 1,04 mmol/l(pour les hommes), pression artérielle systolique et dias-tolique (PAS/PAD) ≥ à 130/85 mm Hg ou traitement anti-hypertenseur et glycémie à jeun ≥ 6,1 mmol/l.

Les données de notre étude ont été saisies et analyséesà l’aide du logiciel SPSS. Les variables étaient décritespar un indicateur de tendance centrale (proportion oumoyenne) et par un indicateur de dispersion (écart-type). La comparaison des pourcentages était faite àl’aide du chi carré et celles des moyennes par le test t destudent et l’analyse de variance. Le seuil de significationretenu était de 5 %.

RESULTATS

Caractéristiques générales de la population étudiée

Il s’agissait d’une population masculine âgée de 35 ± 7ans. Près de la moitié (48,9 %) des enquêtés était âgés de35 ans et plus. Plus de 42 % de ces sujets relevaient de l’ar-mée de terre et 12,8 % étaient des ouvriers civils de l’ar-mée employés dans le domaine du génie civil. Le tableauN° 1 précise la distribution de la population d’étude enfonction de l’âge, du grade et de l’armée d’appartenance.Le tableau N° 2 objective les caractéristiques générales dela population d’étude en fonction de la classe d’âge.

La prévalence du diabète (≥ 7 mmol/l) était de 3,8 %chez les 35 ans et plus de notre cohorte et augmentaitsignificativement avec l’âge (6,7 % chez les 40 ans etplus; p = 0,002). Celle de l’HTA (140/90 mm Hg) était de7,6 % chez les 35 ans et plus et augmentait avec l’âge(12,6 % chez les 40 ans et plus; p < 0,0001). Les préva-lences de l’obésité (IMC ≥ 30) et de la surcharge pondé-rale (IMC comprise entre 25 et 29,9) étaient respective-ment de 12,1 % et 40,3 %. Elles augmentaient significa-tivement avec l’âge (16 % et 44,9 % chez les 35 ans etplus - 18,9 % et 47,4 % chez les 40 ans et plus; p< 0,0001). La sédentarité (activité physique < 30 mn3j/semaine) était retrouvée chez 40,9 % de la popula-tion étudiée. Elle était significativement plus prononcéechez les sujets âgés de 35 ans et plus (44,3 %; p = 0,038).

7International Review of the Armed Forces Medical Service Revue Internationale des Services de Santé des Forces Armées

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EFFECTIF FRÉQUENCE (%)

GROUPE D’ÂGE (ANS)

20-29 174 24,5

30-39 342 48,2

≥40 193 27,2

CATÉGORIE DE GRADE

Officiers 27 3,8

Sous officiers 303 42,7

Hommes de troupe 288 40,6

Ouvriers civils 91 12,8

ARMÉE

Armée de l’air 158 22,3

Armée de terre 302 42,6

Services communs 249 35,1

Tableau 1 : Distribution du personnel enquêté en fonction del’âge, de la catégorie de grade et de l’armée d’appartenance.

VALEUR MOYENNE

< 35 ANS ≥ 35 ANS TOTAL P

TAS moyenne (mm Hg) 114 ± 10 116 ± 12 115 ± 11 0,008

TAD moyenne (mm Hg) 65 ± 7 66 ± 8 65 ± 8 DNS

IMC (Kg/m2) 24,8 ± 3,2 26,2 ± 3,7 25,5 ± 3,6 <0,0001

TT moyen (cm) 96,9 ± 12,7 100,3 ± 11,8 98,6 ± 12,4 <0,0001

Glycémie moy (mmol/l) 4,65 ± 0,7 5,03 ± 1,45 4,84 ± 1,15 <0,0001

Cholestérolémie moy (mmol/l) 4,00 ± 0,80 4,41 ± 0,81 4,20 ± 0,86 <0,0001

Triglycéridémie moy (mmol/l) 1,23 ± 0,67 1,32 ± 0,78 1,28 ± 0,73 DNS

HDL Cholestérol moy (mmol/l) 1,00 ± 0,40 0,97 ± 0,31 0,98 ± 0,36 DNS

Tableau 2 : Caractéristiques cliniques et biologiques de la population d’étude en fonction de l’âge.


Aucune différence significative n’a été constatée pourla prévalence de l’obésité et de la sédentarité en fonc-tion de l’armée d’appartenance.

Fréquences des anomalies métaboliques

La prévalence de l’hyperglycémie à jeun (≥ 6,1 mmol/l)était de 5,9 %. Elle augmentait significativement avecl’âge (9,1 % chez les 35 ans et plus et 15,1 % chez les40 ans et plus; p < 0,0001) et la classe de l’IMC (11,4 %chez les obèses; p = 0,028). Les fréquences de l’hyper-cholestérolémie (CT > 6,2 mmol/l) et de la cholestérolé-mie limite (CT : 5,2 - 6,2 mmol/l) étaient respectivementde 2,1 % et 9,4 %. Ces valeurs augmentaient significa-tivement avec l’âge (respectivement 4,1 %, 11,6 % chezles 35 ans et plus; p < 0,0001). Celle de l’hypertriglycé-ridémie (> 1,7 mmol/l) était de 7,7 %.

Dans notre cohorte, 11,3 % des sujets ne présentaientaucune anomalie parmi les composantes du syndromemétabolique. Cette proportion était respectivement de37,2 % et 33,9 % pour la présence d’une et de deuxanomalies. Elle était de 13,6 % et 4 % pour la présencede trois et de quatre et plus anomalies.

L’anomalie métabolique individuelle la plus fréquenteétait l’hypo HDL cholestérolémie (69,6 %) suivi parl’élévation du tour de taille (39,1 %) et elle variait avecla classe d’âge avec des valeurs respectives de 71,4 % et44,9 % chez les 35 ans et plus (Graphique N° 1). La pré-valence de ces anomalies variait significativement éga-lement en fonction de la classe de l’IMC (GraphiqueN° 2); elles étaient respectivement de 81,4 % et 85 %chez les obèses (IMC ≥ 30).

Le tableau N° 3 objective les prévalences des anomaliesmétaboliques individuelles et du syndrome métabo-lique dans notre population d’étude en fonction de laclasse de l’IMC.

Prévalence du syndrome métabolique

La prévalence du syndrome métabolique était de17,6 % dans notre cohorte. Elle variait significativementavec l’âge (10,8 % chez 20-29 ans, 14,5 % chez les 30-39ans et 28,2 % chez les 40ans +; p = 0,003). Elle était de24,0 % chez les 35 ans et plus contre 11,4 % chez les

moins de 35 ans (p = 0,004). Elle ne variait pas significa-tivement dans notre série en fonction du statut militaireou civil ni en fonction de l’armée d’appartenance.

La prévalence du syndrome métabolique était plus élevéechez les militaires présentant une surcharge pondéraleou une obésité (25,1 %) contre 8,4 % chez le reste de la


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Total≥ 35 ans

Hypertriglyc(>1,6 mmol/l)

Hypo HDL chol(1,04 mmol/l)

Hyperglycémie(≥6,1 mmol/l)

Elévation du TT(>102 cm)

Elévation PA(≥ à 130/85 mm Hg)

< 35 ans

0 10 20 30 40 50 60 70 80

Prévalence des anomalies métaboliques

Type

s de

s an

omal

ies

mét

abol

ique

s 22,724,7

20,7

DNS

DNS69,671,4

67,85,99,1

2,939,144,9

33,615,619,5

11,9

P<0,001

P<0,001

P=0,004

Graphique 1 : Prévalence des anomalies métaboliquesindividuelles chez les militaires du sud tunisien

en fonction du groupe d’âge en 2008.

Hypertriglyc(>1,6 mmol/l)

Hypo HDL chol(1,04 mmol/l)

Hyperglycémie(≥6,1 mmol/l)

Elévation du TT(>102 cm)

Elévation PA(≥ à 130/85 mm Hg)

Prévalence des anomalies métaboliques individuelles

Type

s de

s an

omal

ies

mét

abol

ique

s in

divi

duel

les

0 20 40 60 80 100

IMC≥30

IMC<30

P<0,0001

P<0,0001

P=0,019

P=0,004

13,731

32,585

4,911,4

67,381,4

20,335,1

P=0,028

Graphique 2 : Prévalence des anomalies métaboliquesindividuelles chez les militaires du sud tunisien

en fonction de la classe de l’IMC en 2008.

% DANS NOTRE ÉTUDE % DANS L’ÉTUDE DE JABER

IMC < 30 IMC > 30 P IMC < 30 IMC > 30 P

Elévation PA (≥ à 130/85 mm Hg) 13,7 31 <0,0001 19,8 33,4 0,035

Elévation du TT (> 102 cm) 32,5 85 <0,0001 3,7 51,8 <0,0001

Hyperglycémie (≥ 6,1 mmol/l) 4,9 11,4 0,028 29,6 39,2 0,18(*)

Hypo HDL chol (1,04 mmol/l) 67,3 81,4 0,019 35,5 55,5 0,007

Hypertriglyc (>1,6 mmol/l) 20,3 35,1 0,004 34,2 47,5 0,070

(*) : Différence non significative.

Tableau 3 : Prévalence des anomalies métaboliques individuelles dans notre cohorteet dans celle de la population masculine des arabes américains en fonction de l’IMC.


population (p < 0,0001). Elle était également plus impor-tante chez les sédentaires (25 %) contre 14,5 % chez lessujets actifs (p = 0,017). La prévalence du syndrome méta-bolique variait significativement en fonction de la classede l’IMC (45,5 % chez les IMC ≥ 30 contre 13 % chez lesIMC < 30; p < 0,0001).

La régression logistique confirme bien les résultats del’analyse bivariée. L’âge est significativement associé ausyndrome métabolique : les personnes âgées de 35 anset plus avaient un risque deux fois plus élevé que lesjeunes. Les obèses enregistraient un risque cinq foisplus élevé que les individus ayant un IMC normal(tableau N° 4 et Graphique N° 3).

DISCUSSION

De nombreuses enquêtes épidémiologiques ont étéconduites de part le monde afin de déterminer la pré-valence des troubles et du syndrome métaboliques15-18.L’épidémie mondiale de ces troubles est hétérogène etvarie selon les différents groupes ethniques et culturels,le degré d’urbanisation, la composition démogra-phique et les conditions socio-économiques.

Près du cinquième de notre population militaire mas-culine présentait en 2005 un syndrome métabolique etcette prévalence augmentait significativement avec

l’âge, l’obésité et la sédentarité. L’étude menée à Tunisen 1994 a révélé une prévalence du syndrome métabo-lique de 24,3 %15 avec une prédominance féminine(30,8 % contre 14,6 % dans la population masculine).Celle de l’enquête nationale de nutrition de 1996, aobjectivé une prévalence de 16,3 %16 avec égalementune prédominance féminine (17,7 % contre 13,2 %chez les hommes). En 2005, une tendance à la hausse decette fréquence a été observée en Tunisie; elle a prati-quement doublé en une décennie pour passer à 30 %avec toujours une nette prédominance féminine(36,1 % contre 20,6 % chez les hommes). Elle est plusfréquente en milieu urbain dans les deux sexes, dans lesgroupes les plus éduqués et ceux ayant des antécédentsfamiliaux de maladies cardiovasculaires pour leshommes et après la ménopause pour les femmes17.

Ces valeurs observées en Tunisie étaient proches descelles trouvées dans les pays occidentaux avec des varia-tions selon le genre diversement appréciées. Aux EtatsUnis, elle était passée de 23,1 % NIHANES III (1988-1994) à 26,7 % NIHANES III (1999-2000). Ford et al. ontestimé en 2002 cette prévalence à 23,7 % avec 24 %pour les hommes et 23,4 % pour les femmes18. EnFrance, cette fréquence a été évaluée en 2004 à 15 %19,

20. En Finlande, la prévalence du syndrome métabo-lique était plus élevée chez les hommes que chez lesfemmes durant les années 1992 et 2002. La hausse étaitplus marquée dans la population féminine où la préva-lence était passée de 32,2 % à 39,1 % alors que pour lapopulation masculine de 48,8 % à 52,6 %21.

Le milieu militaire ne semble pas épargné de ce pro-blème de santé publique malgré ses particularités enrapport avec la sélection médicale imposée au recrute-ment et le mode de vie basé sur une activité physiquerégulière et souvent soutenue. La prévalence du syn-drome métabolique était de 17,6 % chez les militairesde la marine brésilienne et près du tiers des sujets étu-diés présentaient deux facteurs de risques ou plus de cesyndrome22. Pour les militaires français, la prévalencedu syndrome métabolique était de 9 % avec un âge etun IMC significativement plus élevés chez les sujetsatteints. La fréquence du tabagisme, de la sédentaritéet des antécédents familiaux de diabètes et d’hyper-tension artérielle étaient plus fréquents chez ces mili-taires10, 12. Les valeurs de la cholestérolémie et de la C-réactive protéine étaient également plus élevées. Cetteprévalence était respectivement de 18 % chez lespilotes de l’air de l’Armée Royale Jordanienne11 et de20,8 % chez les militaires saoudiens23. L’obésité abdo-minale était le facteur de risque le plus fréquent chezces derniers (33,1 %) suivi par l’hypertriglycéridémie(32,2 %) puis par l’élévation de la pression artériellesystolique (29,5 %).

Les prévalences des anomalies métaboliques indivi-duelles et du syndrome métabolique dans notre cohortediffèrent peu de celles de la population masculinenationale et de certaines populations masculines arabes(tableaux 3 & 5) ce qui témoigne de l’importance de lamise en place d’une stratégie de prévention en milieumilitaire. Cette stratégie doit porter sur la promotion

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Graphique 3 : Association de l’âge et de l’obésité au syndromemétabolique chez les militaires du sud tunisien en 2008.

109

876

5

43210

>=35 ans Obèse

MODÈLE 1* MODÈLE 2** P (WALD’S)

OR BRUT [IC] OR AJUSTÉ [IC]

Age <0,001

<35 ans 1

≥35 ans 2,3 [1,4-4,0] 1,9 [1,1-3,5] <0,001

Obésité <0,001

Normal 1 <0,001

Obèse 5,6 [3,0-10,3] 4,9 [2,6-9,3] <0,001

* Modèle 1 : association brute** Modèle 2 : associations ajustées sur les facteurs âge et obésitéOR : Odds-ratio de la catégorie par rapport à la catégorie de référenceIC : Intervalle de confiance (P = 0,95)

Tableau 4 : Facteurs associés au risque cardiovasculaire.


d’une hygiène de vie avec l’adoption d’une alimenta-tion saine et équilibrée et d’une activité physique régu-lière. La prise en charge du syndrome métaboliquepasse par des mesures hygiéno-diététique, comprenantrégime alimentaire et exercice physique. En secondeintention des traitements médicamenteux peuvent êtreadjoints.

CONCLUSION

Le syndrome métabolique correspond à l’associationd’une obésité dite « viscérale, de perturbations lipi-diques, glucidiques, et d’une hypertension artérielle.C’est un facteur prédictif de la survenue d’un diabètede type 2 et un facteur de risque cardio-vasculaire. Latendance à l’urbanisation et la modernisation qui sontnouvelles à notre société ouvrent la voie à l’apparitionde multiples troubles métaboliques, dont leurs associa-tions forment le syndrome métabolique; avec toutesleurs lourdes conséquences sur l’individu et la société. Du fait que ce problème de santé commence à s’instal-ler en milieu militaire, il est recommandé de mettre enplace un programme de lutte et prévention contre cefléau et qui tient compte des spécificités du milieu mili-taire. Il doit contrôler tout changement néfaste dumode de vie et veiller à faire adopter une alimentationsaine et une activité physique permanente. Parfois, unethérapeutique médicamenteuse constitue le principalvolet de prise en charge de ce syndrome.

D’autres études seront menées par le service de santé desarmées pour suivre la tendance de la prévalence de cesyndrome métabolique dans d’autres régions puis danstoute l’armée et permettre d’offrir aux militaires dépistésune meilleure prise en charge de leurs facteurs de risque.

RÉSUMÉ

Introduction : La Tunisie a entamé depuis quelquesannées une triple transition démographique, nutrition-nelle et épidémiologique1-3 caractérisée par l’accroisse-ment des maladies non transmissibles. Elle est liée auxchangements du mode vie, à l’amélioration du niveausocio-économique et à l’urbanisation. Les troublesmétaboliques représentent les éléments constitutifs dusyndrome métabolique et constituent un des facteursde risque cardiovasculaires. Leurs prévalences ne cessent

d’augmenter en Tunisie4. Les données relatives à lasanté des militaires et civils de l’armée dans ce domainerestent rares.Objectif de l’étude : Estimer la prévalence anomaliesmétaboliques individuelles et du syndrome métabo-lique dans une cohorte de militaires et civils exerçantdans les unités de l’armée du sud tunisien en 2008.Matériel et méthodes : L’enquête populationnelle de2008 sur les facteurs du risque cardiovasculaire chez lepersonnel de l’armée des unités du sud est une étudetransversale descriptive conduite auprès d’une cohortede 709 sujets volontaires âgés de 20 ans et plus de sexemasculin, militaires de carrière et civils de l’armée,encore en activité et exerçant au sud tunisien.Résultats : La prévalence de l’hypercholestérolémie (CT> 6,2 mmol/l) et de la cholestérolémie limite (CT : 5,2 -6,2 mmol/l) étaient respectivement de 2,1 % et 9,4 %.L’anomalie métabolique individuelle la plus fréquenteétait l’hypo HDL cholestérolémie (69,6 %) suivi parl’élévation du tour de taille (39,1 %). Elles variaientsignificativement avec la classe d’âge (71,4 % et 44,9 %chez les 35 ans +) et l’IMC (81,4 % et 85 % chez lesobèses).La prévalence du syndrome métabolique était de17,6 % dans notre cohorte. Elle variait significative-ment avec l’âge (10,8 % chez 20-29 ans, 14,5 % chez les30-39 ans et 28,2 % chez les 40 ans +; p = 0,003) maisne variait pas en fonction du statut militaire ou civil nien fonction de l’armée d’appartenance. Elle était plusélevée chez ceux présentant une surcharge pondéraleou obésité (25,1 %) et chez les sédentaires (25 %).Conclusion : Le syndrome métabolique commence às’installer en milieu militaire. Il est de ce faite recom-mandé de mettre en place un programme de lutte etprévention contre le risque cardiovasculaire en milieumilitaire. Il doit contrôler tout changement néfaste dumode de vie et veiller à faire adopter une alimentationsaine et une activité physique permanente. Parfois, unethérapeutique médicamenteuse constitue le principalvolet de prise en charge de ce syndrome.

BIBLIOGRAPHIE

11. BEN ROMDHANE H, KHALDI R, OUESLATI AM, SKHIRIAOUNALLAH H. La transition épidémiologique en Tunisie,ses déterminants et son impact sur les systèmes de santé.Options méditerranéennes, la surveillance nutritionnelleen Tunisie 2002; Série B; Etudes et recherches (41) : 7-28.


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PRÉVALENCE (%) DES ANOMALIES MÉTABOLIQUES INDIVIDUELLES

NOTRE ÉTUDE TAHINA (17) AL LAWATI (24) JABER (25)

Elévation PA (≥ à 130/85 mm Hg) 15,6 47,6 27,9 23,9

Elévation du TT (> 102 cm) 39,1 20,6 24,6 17,7

Hyperglycémie (≥ 6,1 mmol/l) 5,9 15,2 19,2 38,5

Hypo HDL chol (1,04 mmol/l) 69,6 - 75,4 41,5

Hypertriglyc (>1,6 mmol/l) 22,7 56,6 20,0 32,8

SYNDROME MÉTABOLIQUE 17,6 20,6 19,5 19,8

Tableau 5 : Prévalence des anomalies métaboliques individuelles dans notre étude et dans certaine population masculine arabes.


12. BEN ROMDHANE H. Les cardiopathies ischémiques.L’épidémie et ses déterminants. Volume I : Les facteurs derisque, Résultats d’une étude épidémiologique auprès de5 771 adultes tunisiens. Publication de l’Institut Nationalde Santé Publique. 2001.

13. GHANEM H, HADJ FRADJ A. Transition épidémiologiqueet facteurs de risque cardiovasculaire en Tunisie. RevEpidem et Sante Publ, 1997, 45, 286 – 92.

14. ESSAIS O, JABRANE J, BOUGUERRA R, EL ATTI J, BENRAYANA C, GAÏGI S, BEN SLAMA C, ZOUARI B. Distributionet prévalence des dyslipidémies en Tunisie : Résultats del’enquête nationale de nutrition. La Tunisie Medicale,2009; Vol 87 (n° 8) : 505-10.

15. ALLANI R, SKHIRI H, BACHROUCH S, MOUAOUI N,BELLAAJ R, GHYOULA M, BEN ROMDHANE H. Les facteursde risque cardio-vasculaire chez une population militaire :Le point de vue du médecin d’unité. Revue Tunisienne dela Santé Militaire 2005; 7 : 320-6.

16. ALLANI R, AMORRI W, AYADI N, MEHDI F, ASLI S,BOUOMRANI S, BELLAAJ R, FARAH A, BÉJI M. Prévalencesdu diabète et de l’HTA et fréquences de certains facteursde risque cardiovasculaires dans une cohorte de l’arméeau sud tunisien. Revue Internationale des Services deSanté des Armées, 2012,Vol.85 (1) : 21-30.

17. REVEL F, CHARRUT JC, NIEZ P, LE GUYADEC T, MAYAUDONH, LEGRELLE M, BAUCUCEAU B, GAUTIER D. Facteurs derisque cardio-vasculaire : approche épidémiologique enmilieu militaire. Médecine et Armée. 1993,vol.21,n° 8,601-6.

18. BÉJI M, GABSI N, FAKHFAKH R, HSAIRI M. Etude épidémiolo-gique du tabagisme en milieu militaire dans le sud tunisien.Revue Tunisienne de la Santé Militaire 2002; 4 : 63 -70.

19. GOTTO AM Jr, WHITNEY E, STEIN EA et al. Relation bet-ween baseline and on-treatment lipid parameters andfirst acute major coronary events in the Air Force/TexasCoronary Atherosclerosis Prevention Study.(AFCAPS/TexCAPS). Circulation. 2000; 101 : 477-484.

10. BAUDUCEAU B, BAIGTS F, BORDIER L, BURNAT P, CEPPA F,DUMENIL V, DUPUY O, LE BERRE JP, MAYAUDON H,PAILLASSON S. Epidemiology of the metabolic syndromein 2045 French military personnel (EPIMIL study). DiabetesMetab. 2005 Sep; 31 (4 Pt 1) : 353-9.

11. KHAZALE NS, HADDAD F. Prevalence and characteristics ofmetabolic syndrome in 111 Royal Jordanian Air Forcepilots. Aviat Space Environ Med.2007 Oct; 78 (10) : 968-72.

12. CEPPA F, MERENS A, BURNAT P, MAYAUDON H,BAUDUCEAU B. Military community : a privileged site forclinical research : Epidemiological Study of MetabolicSyndrome Risk Factors in the Military Environment. MilMed. 2008 Oct; 173 (10) : 960-7.

13. American Heart Association. Third Report of the National

Cholesterol Education Program (NCEP) Expert Panel onDetection, Evaluation, and Treatment of High BloodCholesterol in Adults (Adult Treatment Panel III) FinalReport. Circulation. 2002; 106 : 3143.

14. Joint Scientific Statement Harmonizing the MetabolicSyndrome. Circulation. 2009; 120 : 1640-1645.

15. HARZALLAH F, ALBERTI H, BEN KHALIFA F. The metabolicsyndrome in an Arab population : a first look at the newInternational Diabetes Federation criteria. Diabet Med.2006; 23 : 441-4.

16. BOUGUERRA R, BEN SALEM L, ALBERTI H, BEN RAYANA C,EL ATTI J, BLOUZA S, GAIGI S, ACHOUR A, BEN SLAMA C,ZOUARI B. Prevalence of metabolic abnormalities in theTunisian adults : a population based study. DiabetesMetab 2006; 32 : 215-221.

17. BELFKI H, BEN ALI S, AOUNALLAH-SKHIRI, H TRAISSAC P,BOUGATEF S, MAIRE B, DELPEUCH F, ACHOUR N, BENROMDHANE H. Prevalence and determinants of the meta-bolic syndrome among Tunisian adults : results of theTransition and Health Impact in North Africa (TAHINA)project. Public Health Nutrition : 8/2012; 16 (4), 582 – 90.

18. FORD E S, GILES W H, MOKDAD A H. Increasing preva-lence of the metabolic syndrome among U.S. adults.Diabetes care. 2004 Octobre; 27 (10) : 2444-9.

19. LEJEUNE H, DESCAZEAUD A. Le syndrome métabolique :épidémiologie et physiopathologie. Sexologies. 2007; 16(S1-S5) : 51-5.

20. BALKAU B, VERNAY M, MHAMDI L, NOVAK M, ARONDELD, VOL S, TICHET J, ESCHWÈGE E. The Incidence and per-sistence of the NCEP (National Cholesterol EducationProgram) metabolic syndrome. The French D.E.S.I.R. study.Diabetes Metab 2003; 29 : 526-32.

21. HU G, LINDSTRÖM J, JOUSILAHTI P, PELTONEN M,SJÖBERG L, KAAJA R, SUNDVALL J, TUOMILEHTO J. Theincreasing prevalence of metabolic syndrome amongFinnish men and women over a decade. J Clin EndocrinolMetab. 2008 Mars; 93 (3) : 832-6.

22. COSTA FF, MONTENEGRO VB, LOPES TJ, COSTA EC.Combination of risk factors for metabolic syndrome in themilitary personnel of the Brazilian Navy. Arq Bras Cardiol.2011 Dec; 97 (6) : 485-92.

23. AL-QAHTANI DA, IMTIAZ ML. Prevalence of metabolicsyndrome in Saudi adult soldiers. Saudi Med J. 2005 Sep;26 (9) : 1360-6.

24. AL-LAWATI JA, MOHAMMED AJ, AL-HINAL HQ,JOUSILAHTI P. Prevalence of the metabolic syndromeamong Omani adults. Diabetes Care 2003; 26 : 1781-5.

25. JABER LA, BROWN MB, HAMMAD A, ZHU Q, HERMANWH. The prevalence of the metabolic syndrome amongArab Americans. Diabetes Care 2004; 27 (1) : 234-8.

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Par L. AIGLE�, F. LIMAS�, C. BAY� et J. SAMY�. France

Luc AIGLE

Fait clinique : un éclat suspect !

Entré à l’Ecole du service du service de santé de Bordeaux en 1992, le médecin-chef AIGLE a servi successivement au 1er RCP, au 2ème REP à la 13ème DBLE, au 1er

RPIMa. Il a pris le commandement du CMA de Calvi (2ème REP) depuis l’été 2013.Breveté « chuteur opérationnel » depuis 2002 et formé au saut à Très Grande Hauteur,

il est l’auteur d’une thèse de médecine sur « Le stress au cours du saut opérationnel à trèsgrande hauteur : apport du HOLTER ECG ».Le MC AIGLE est, par ailleurs à l’origine du développement du secourisme au combat au sein du GCP, dès2004, puis des unités de la 11ème BP.Plusieurs fois cité, il a participé à de nombreuses opérations extérieures, notamment en Afrique et enAfghanistan.


ARTIC

LES

ARTIC

LES

SUMMARY

Case Report: A Suspect Shrapnel !

Trough the case report of a war wound management in a soldier with massive hemorrhage, we review this type of event in militaryand particular situation of war environment. The intense stress caused by a fight may induce wrong reactions or wrong procedureswhich could lead to wrong diagnosis and errors during the evacuation chain.

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MOTS-CLÉS : Blessés de guerre, Geste iatrogène, Sauvetage au combat, Stress.KEYWORDS: Combat casualty care, Iatrogenic act, Stress, War casualty.

INTRODUCTION

La prise en charge d’un blessé de guerre dans une zonede combats est une des caractéristiques particulièresd’exercice du métier de médecin militaire. Celui-ci doitconcilier deux problèmes a priori incompatibles : d’unepart le diagnostic et la prise en charge rapide et d’au-tre part un environnement particulièrement hostilepour lui comme pour le malade. Par ce cas clinique noussouhaitons revenir sur la prise en charge d’une hémor-ragie massive en milieu militaire mais surtout soulignerles effets secondaires inattendus qui peuvent survenirdans ce contexte de stress majeur et influer sur la priseen charge ultérieure.

CAS CLINIQUE

Contexte

Lors d’un détachement d’assistance opérationnellemené par des commandos parachutistes dans un paysafricain, ceux-ci sont victimes d’une embuscade.

Au moment de l’accrochage (17 heures environ) les

Français sont répartis en deux groupes de part et d’au-tre de la piste avec leurs homologues africains. Laconfusion est importante car la vision est réduite en rai-son d’une végétation dense. Le médecin est à 200mètres au carrefour de piste prêt à intervenir avec lesrenforts et suit le combat à la radio. On annonce rapi-dement un mort et peut être un blessé. Quelquesminutes s’écoulent avant l’autorisation de se déplacer.

� MC, praticien confirmé,CMA CALVI, camp Raffalli, 20260 Calvi.

� MC, praticien confirmé,Commando Hubert, CC319 Toulon Cedex 9.

� MC, praticien certifié,département de préparation milieux et opérationnelle, EVDG.

� MP, docteur en médecine,Antenne Médicale Spécialisée de Bayonne, BP 60806, 64108 Bayonne Cedex 08.

Correspondance :Luc AIGLE,CMA Calvi, camp Raffalli20260 [email protected]él : 06 83 90 14 64

Eclat Suspect_AIGLE_Mise en page 1 13/03/14 18:14 Page1

Prise en charge sur le terrain

Arrivés sur la ligne de contact, la fusillade est toujoursintense et c’est le dos courbé que nous nous jetons au piedde notre camarade déjà exsangue. Du sang macule lesdeux jambes du pantalon et un pansement sommaire-ment posé par un combattant expulse de « gros boudins »de sang coagulé à gauche.

La prise en charge consiste alors à poser deux garrots pourstopper les hémorragies et à immédiatement déclencherune demande d’évacuation par hélicoptère (EVS) car ledélai d’arrivée est d’une heure de vol au minimum. Dansle même temps, le chef de section demande la possibilitéd’extraire le blessé de la zone, mais il lui est demandé detemporiser car le patient encore particulièrement instablepeut désamorcer à tout moment.

Deux voies veineuses périphériques sont posées aux deuxplis du coude avec un soluté de remplissage protéiqueHEA et un sérum salé isotonique « écrasé » par un militairepour obtenir un débit maximum. Le blessé est subcons-cient (Glasgow évalué a posteriori à 11), il parle en anglaissans pouvoir répondre aux questions, le pouls n’est paspalpable. C’est une fois l’hémorragie externe contrôléepar les garrots et le remplissage que de la morphine titrée(3x2 mg/5 min) et deux bolus de 3 mg d’éphédrine lui sontadministrés.

En attendant le véhicule d’évacuation, le pantalon estdécoupé pour explorer les lésions. celles-ci s’apparententà une blessure par éclats de RPG 7 (lance-roquettes antichar) car il existe un orifice d’entrée au niveau de bordexterne du péroné gauche avec un gros délabrement à laface interne du mollet (photo n° 1), un poly criblage dansle mollet droit (face interne) avec plusieurs orifices de sor-tie sur le bord externe. Le saignement abondant est exté-riorisé à gauche et semble plutôt interne à droite avec unmollet déjà augmenté de volume.

Poursuite de la mise en condition d’évacuation

Après une quinzaine de minutes, une extraction parvéhicule est effectuée.

Une fois en lieu sûr, la prise en charge est poursuivie denuit à l’éclairage d’une lampe frontale en reprenant

une à une les blessures avec nettoyage des plaies àl’eau puis pansements iodés. Enfin une tentative dedesserrage des garrots est effectuée. Ils sont laissés enplace pour le transport (garrot d’attente) au cas où lesaignement reprendrait. On surélève les deux jambesqui sont fixées sur des attelles (photo n° 2). Il reçoit 1 gde paracétamol en IV puis 2 g d’amoxicilline et acideclavulanique en IV ainsi que du sufentanyl en titration(2x5 µ) pour obtenir une échelle visuelle analogique (EVA)inférieure à 3. Au total environ un litre de sérum salé iso-tonique et un litre de soluté de remplissage protéiqueHEA auront été administrés avant sont évacuation.

Evacuation

L’hélicoptère d’évacuation arrive environ 1 heure 30après la blessure et décolle après moins de 5 minutespassées sur zone pour des transmissions rapides.

Le patient est ensuite transféré en deux temps (héli-coptère puis avion militaire tactique accompagnéchaque fois par un médecin à bord) vers une antennechirurgicale française où il arrivera peu avant 22h. Il sesera donc écoulé environ 5 heures entre la blessure etsa prise en charge au bloc opératoire.

Au bloc opératoire

Au cours de l’intervention les chirurgiens retrouvent denombreux débris métalliques pouvant s’apparenter àune balle d’AK 47 dans les deux mollets et sont intri-gués par une plaie non mentionnée par le premiermédecin au niveau du flanc droit (photo n° 3). Est-ce unéclat dû à une autre blessure (RPG, mortier) ? Ou est-ceun éclat de la même blessure par balle ? Une explorationest faite mais ne trouve rien de particulier.

L’explication de cette curieuse plaie est donnée le len-demain au réveil par le malade lui-même, qui bien quetrès affaibli, explique qu’au moment du découpage dupantalon il a ressenti un violent coup dans le flanc droitmais, qu’étant trop faible, il n’en a rien pu dire surplace.

En effet, le médecin avait procédé au découpage de lajambe gauche du pantalon avec les ciseaux à vêtements


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Photo 1.

Photo 2.


qui, dans le stress de la situation, étaient tombés dansles hautes herbes. Un soldat a aussitôt donné son cou-teau et d’un geste rapide, le médecin découpait ladeuxième jambe de pantalon… finissant sans s’en rendrecompte et bien malgré lui dans le flanc du blessé.

Au total ce militaire a été victime d’une très grave bles-sure par balle d’AK 47 qui, en percutant le péronégauche s’est disloquée en provoquant plusieurs éclats.Ceux-ci ont entraîné une hémorragie massive par rup-ture quasi complète de l’artère poplitée gauche ainsique du nerf sciatique poplité externe (SPE) gauche avecimportante perte de substance du mollet. Un poly cri-blage du mollet droit avec section de l’artère poplitéedroite et du SPE droit complète ce tableau lui laissantaujourd’hui encore de très lourdes séquelles.

DISCUSSION

Stratégie de prise en charge du blessé de guerre

L’engagement Français en Afghanistan a permis laréévaluation en profondeur du système de relevagedes blessés de guerre. Ainsi, les acteurs de la chaînemédicale de l’avant ont reçu des formations et puacquérir des qualifications permettant d’optimiser laprise en charge tout en bénéficiant des derniers pro-grès techniques et matériels. Nous ne parlerons ici quedu rôle 1, correspondant au relevage et à la mise encondition d’évacuation par l’équipe médicale vers unestructure chirurgicale (rôle 2 ou 3).

Ainsi chaque combattant a-t-il reçu une formation deSauvetage au Combat de niveau 1, le SC11 et été équipéd’une Trousse Individuelle du Combattant (TIC) qu’ildoit porter sur le gilet pare-balles. Celle-ci est consti-tuée d’un garrot tourniquet, d’un pansement compres-sif, d’un kit de perfusion avec du Sérum SaléHypertonique (SSH), de deux syrettes de morphinedosées à 10 mg/1 ml en sous cutané ainsi que de quoiréaliser une désinfection (photo n° 4).

L’objectif est que tout militaire soit capable de réaliserles gestes de sauvetage à l’avant, à savoir la pose dugarrot, dit « garrot d’attente », la pose du pansement

compressif, la mise en position d’attente (position laté-rale de sécurité pour les inconscients, demi-assise pourles blessés du thorax ou encore allongée jambe surélevéepour les blessés abdominaux), la pose d’un pansementtrois côtés sur une blessure thoracique et l’injection demorphine en sous cutané.

La TIC permet d’apporter au plus près du combattantde quoi effectuer un remplissage par l’équipe médicale.Ce SC1, premier maillon de cette chaîne de sauvetage etprimordial quand on sait que près de 80 % des morts aucombat le sont par hémorragie externe non contrôlée2,c’est le concept des morts évitables3.

La formation appelée Sauvetage au Combat de niveau 2,le SC24, 5 est venue compléter la formation de nos auxi-liaires sanitaires par l’apprentissage de gestes spécifiquesde sauvetage du blessé de guerre (exsufflation d’unpneumothorax suffocant, pose de voies veineuses péri-phériques et voie intra-osseuse, de pansements hémosta-tiques, crycothyroïdotomie) ainsi qu’une formationapprofondie à la gestion des blessés de guerre basée surun schéma standardisé de prise en charge résumé parl’acronyme SAFE MARCHE RYAN (tableau n° 1). Cetteméthode de réflexion est une adaptation du TacticalCombat Casualty Care ou T3C américain (version militairedu PHTLS) aux concepts français sur le relevage et lamédicalisation de l’avant. Le processus de prise en chargedu blessé de guerre, les gestes invasifs et les protocolesthérapeutiques sont enseignés au Centre de FormationOpérationnelle Santé de La Valbonne et font l’objetd’une formation continue annuelle dans les centres médi-caux des armées. Ces militaires ainsi formés ne sont auto-risés à pratiquer ces gestes qu’en opérations extérieuresou en situation de grand isolement.

Enfin pour les médecins et les infirmiers, le Sauvetageau Combat de niveau 3, le SC3, correspond à un ensem-ble de compétences dans le domaine de la médecine deguerre. On y retrouve notamment une standardisationde la prise en charge avec des gestes techniques et desdrogues simples, fiables, éprouvées dans le contexte del’urgence de l’avant (morphine, kétamine, adrénaline,midazolam, atropine par exemple).

Des stages médicaux collant au plus près de la réalité sontorganisés régulièrement pour les équipes partant en


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Photo 3. Photo 4.


mission avec le concours des médecins rentrants d’opéra-tions. Cela permet de transmettre « à chaud » l’expérienceet d’améliorer encore les matériels et techniques : Stage demise en condition de survie d’un blessé de guerre au

centre d’instruction et techniques de réanimation del’avant (CITERA); stage sur la prise en charge d’un brûlé aurôle 1; stage de formation à l’échographie d’urgence; stagede médicalisation en milieu hostile (MEDICHOS).

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SAFE

S Stop the burning processSupprimer la menace

Répliquer par les armes, faire intervenirles équipes spécialisées

A Asseess the sceneAnalyse de la situation

Analyser, donner les ordres, que s’est-ilpassé ?

F Free of danger for youFin du danger, ne pas s’exposer

Mettre à l’abri, extraire

E Evaluate forEvaluer

Victime unique : MARCHEMulti victimes : START ABC

MARCHE

M Massive bleeding controlTraquer les hémorragies et les arrêter

Garrot tourniquetPansement compressifPansement hémostatiqueImmobilisation bassin

A AirwaysEst-ce que l’air passe ? ! trauma du rachis ?

LVA, PLS, Position ½ assiseConiotomieCollier cervical

R Respiration Comment respire le blessé ?

- Amplitude et symétrie des 2 champs pulmonaires

- Fréquence : 8 à 30 / min

Pansement 3 côtésExsufflationPosition adaptée

C CirculationAbsence de pouls radial ?

- Objectif : pouls présent = PAM 90mmHg

Appel SC2 ou personnel habilitéVVP ou DIORemplissage vasculaire Expansion volémique

H Head / hypothermia- A V P U- Pupilles- motricité

Détresse neurologique - PLS - Immobiliser

Protection thermique - Protéger du sol - Couvrir, Réchauffer

E Evacuation 9 LINE / MEDEVAC

BrancardFixation matérielsPréparation DZ

RYAN

R Réévaluer Reprendre le MARCHEPossible relâche du Garrot

Y Yeux et ORL Yeux couvrir un œilRecherche TSA : Blast ?

A AnalgésieCalmer la douleur

RassurerImmobiliserAnalgésie MorphinePosition d’attente

N NettoyerPrévenir l’infection

NettoyerPansementAntibiotiques

Tableau 1: Sauvetage au combat 1.


Un référentiel pédagogique a été réalisé par le comitéopérationnel pour l’enseignement du sauvetage aucombat, validé par le directeur de l’Ecole du Val-De-Grâce et réévalué chaque année6.

Comparaison avec le cas clinique

Au moment de l’intervention décrite, tout ce dispositifn’avait pas encore vu le jour et la rapidité de déclen-chement de la mission avait fait que le médecin avaitdû partir sans infirmier ni auxiliaire sanitaire. Leconcept de S.A.F.E M.A.R.C.H.E R.Y.A.N n’existait pasencore de manière structurée, mais on en retrouvetoutes les composantes dans la démarche de prise encharge :

SAFE

Riposte immédiate par les équipiers : S (Savoir répliquer parles armes).

Attente d’une situation claire tactiquement avant d’en-gager le médecin : A (Appréhender la scène dans sa globalité),F (Free of danger for you).

Evaluation médicale rapide du médecin : E

MARCHE

Contrôle des hémorragies : M (massive bleeding control),Elle fut faite par le garrot alors en dotation car les tour-niquets américains n’étaient pas encore disponibles, etla pose de deux pansements compressifs. Toute cettepremière étape normalement du ressort des combat-tants a été réalisée ici par le médecin ce qui n’est pasclassique en raison de la situation tactique.

Les équipes médicales ont désormais à leur dispositionle pansement hémostatique « quick clot combatgauze », très efficace pour contrôler les hémorragiesnon accessibles au garrot (zones frontières, creux axil-laire et pli inguinal notamment). Ce pansement dégagemoins de chaleur que les premiers modèles initialementen dotation (à base de granules) le rendant ainsi plusfacile d’utilisation. La mise en place de ces pansementsest enseignée lors du stage SC27.

Le A (airway) et le R (respiration) ne posaient pas de problèmesici.

Pour le C (circulation), il n’y avait ni Trousse Individuelledu Combattant (TIC), ni donc de pré positionnement desoluté de remplissage (SSH) qui auraient permis de rem-plir un peu moins le patient8 et de le stabiliser plus rapi-dement pour le sortir de la zone des combats dans desconditions satisfaisantes sans risque de désamorçage.

La prévention de l’hypothermie a été faite une fois leblessé extrait de la zone des combats : H (head, hypother-

mia). C’est un point important de la prise en charge àl’avant. Les blessés de guerre en grande hémorragiesont très rapidement en hypothermie, ce qui aggraveles troubles de la coagulation et complique leur priseen charge chirurgicale ultérieure9. Un gros effort est

fait pour sensibiliser les médecins d’unité à la mise enplace de cette protection thermique le plus précoce-ment possible (couverture de survie et sac de couchagevisible sur la photo n° 1). De nombreux modèles de pro-tection thermique sont disponibles sur le marché (readyheat cap, blizzard blanket, hypothermia preventionand managment kit par exemple).

La fiche médicale de l’avant (FMA) a été réalisée unefois à l’abri et le malade stabilisé : E (evacuation).

Puis la partie R.Y.A.N a été reprise :

R : La réévaluation complète du blessé a été faite par lemédecin une fois à l’abri. C’est à ce moment de la priseen charge que les nouvelles recommandations concer-nant l’utilisation d’un anti fibrinolytique, l’acide tra-nexamique10, 11 dans le cadre de la gestion d’une hémor-ragie massive sont en faveur d’une injection précoce de2 ampoules (idéalement dans la première heure). Ce trai-tement est désormais disponible dans les rôles 1 pour lesmédecins d’unité. Il aurait été licite de le faire pour notrepatient au moment de cette réévaluation.

Y : (yeux et ORL) sans problème ici.

A : La poursuite de l’antalgie par le sufentanyl en relaisde la morphine initiale a été très efficace mais imposeune titration fine et une surveillance rapprochée tou-jours délicate dans ce contexte. On aurait pu y associerdu midazolam ainsi que de la kétamine pour optimiserl’analgésie avec l’avantage qu’on lui connaît sur la sta-bilité tensionnelle12. L’antibiothérapie a été faite pré-cocement. Les recommandations de 2010 préconisent lecoamoxiclavulanate en première intention sur ce typede plaie ou l’association gentamicine et clindamycineen cas d’allergie aux pénicillines13.

N : Le nursing a été complété par la réfection de tousles pansements et l’immobilisation des deux jambesdans des attelles métalliques en dotation.

L’acronyme S.A.F.E M.A.R.C.H.E R.Y.A.N a l’énormeavantage de donner un cadre aux intervenants santédans cet environnement de combat. Véritable « Checklist » à l’instar des pilotes, il permet à tous de s’appuyersur une référence à tout moment et diminue ainsi lerisque d’oublier une étape importante de la prise encharge. Il donne en outre un langage commun pourtous les acteurs de la chaîne d’évacuation dont on a vuqu’elle pouvait être dans ce contexte militaire longueet aléatoire.

Autres caractéristiques de la prise en charge d’unblessé au combat

L’isolementC’est une des caractéristiques des missions des com-mandos parachutistes, des commandos de montagne etdes forces spéciales. Cela nécessite pour le médecind’avoir une solide expérience tant dans le domainemilitaire que de l’urgence. Il doit avoir anticipé toute la


VOL.87/1


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chaîne d’évacuation car les délais sont capitaux et lesouci permanent du médecin sera de les réduire. Lemaillage sanitaire et la régulation médicale en Francerendent bien différente la prise en charge primairetype SAMU même en zone rurale (ici élongation deplus de 5 h). L’importance de cet isolement condition-nera l’attitude thérapeutique adoptée qui pourra doncêtre différente pour un même blessé (autotransfusion,ventilation mécanique…).

Alerte et moyens de communicationIls revêtent en opération une importance majeure. Enraison des délais, le message d’alerte doit être donné leplus rapidement possible après une évaluation rapidede la gravité : dans ce cas clinique, elle est déclenchéeaprès les deux garrots et avant tout le reste. Lademande de décollage de l’hélicoptère est faite au chefde section qui dans le même temps continue à gérer lecombat. La transmission des informations médicales nedoit pas être négligée. Ici 3 médecins différents ont suivice blessé avant son arrivée sur la table d’opération.

Les moyens modernes de communication (Thuraya,Irridium, Inmarsat) permettent aujourd’hui de pouvoirtransmettre des bilans aux rôles 2 ou 3 assez facilement.

Le stressIl est un facteur majeur dans ce type d’engagement. Ilest à prendre en compte car en plus d’une prise encharge d’un blessé grave, facteur anxiogène classiqueconnu des médecins urgentistes14, 15, se rajoute le stressdu combat (tir, nuit, extraction sous le feu). Pour cetteintervention, ce fut donc un coup de couteau, heureu-sement sans gravité, qui fut l’expression iatrogéniquede cet environnement stressant !

La gestion de ces situations peu fréquentes et horsnormes, nécessite une préparation particulière quipasse par un entraînement militaire minimum et uneformation médicale adaptée (CITERA, MEDICHOS). Lesdifférents thèmes joués avec une simulation haute-fidélité et/ou des blessés grimés permettent, avec lagestion des équipes en situation de crise (crew res-source management), l’acquisition d’un savoir-être. Ils’agit d’une prise de conscience individuelle. En effettout jeune médecin qui choisit cette carrière militairedoit aussi s’y préparer personnellement, Ce type d’évé-nement stressant peut arriver aujourd’hui subitementen dehors de tout contexte de combat, comme ce fut lecas plusieurs fois en Afghanistan avec des attentats sui-cides contre nos soldats16, 17 mais aussi lors de fait diversde notre société moderne (fusillade familiale, sur deslieux publics, règlement de compte…).

Il faut enfin noter l’importance, singulièrement dansles petites unités, de la relation entre l’équipe médicaleet les militaires sur la gestion du stress. Une confiancemutuelle s’installe au fil des entraînements, de la vie encampagne. Cette situation peut amener une contraintesupplémentaire pour le médecin. Dans ce contexte,c’est la prise en charge d’un camarade de combatquand ce n’est pas un ami qu’il doit gérer. Au premiercoup d’œil le médecin a saisi la gravité de la situation

et cela peut jouer négativement sur sa réactivité (stu-peur) alors que le blessé le regarde et lui fait confiance.Il s’ensuit une reconnaissance particulière que l’onretrouve peu souvent après une prise en charge enmilieu civil. Dans notre histoire, après bientôt 7 ans, ladate anniversaire du 1er décembre est toujours l’occa-sion d’un appel ou d’un mail mutuel entre le blessé etle médecin.

CONCLUSION

La prise en charge d’un blessé de guerre tel qu’elle estenseignée dans le service de santé des armées impliquedifférents intervenants : le camarade de combat (SC1),l’auxiliaire sanitaire (SC2) puis l’infirmier et le médecin(SC3). Cette chaîne hautement qualifiée a permis desauver de très nombreux blessés lors des derniers enga-gements. Elle progresse chaque année grâce au retourd’expérience des équipes médicales et à la mise enplace de nouveaux matériels et techniques validésannuellement par un comité. Mais l’environnement decombat dans lequel a lieu cette prise en charge rendson enseignement difficile et reste propre à engendrerdes actions ou un comportement inadapté. C’est doncbien au travers d’un entraînement physique, militaire,intellectuel et psychologique régulier et rigoureux que lemédecin d’unité doit se préparer pour répondre présentle jour « J ».

RESUME

A travers un cas clinique de prise en charge d’un blesséde guerre par hémorragie massive, nous revenons à lafois sur la gestion en milieu militaire de ce type de bles-sure et sur l’aspect particulier que revêt cet environne-ment de combat. Le stress intense généré lors d’unaccrochage, peut entraîner, outre des réactions inadap-tées, des gestes iatrogènes à l’origine d’une errancediagnostic ou de questions de la part des intervenantsultérieurs au cours de la chaîne d’évacuation.

BIBLIOGRAPHIE

11. Référentiel de formation au sauvetage au combat de pre-mier niveau. CISAT.2009.

12. ROUVIER B, PONS F. Traumatismes balistiques graves.Urgences et réanimation en milieu militaire. Arnette1999:31-50.

13. MARTINEZ JY, PUIDUPIN M, PRECLOUX P, KLACK F, TURC J,ESCARMENT J. les enjeux de la prise en charge des blessésdes conflits actuels. Réanoxyo. 2009; 25 (2) : 42-5.

14. INSTRUCTION N° 340143/DEF/RH-AT/PMF/DS/32 - N° 9386/DCSSA/RH/PF relative à la formation des sauveteurs aucombat de deuxième niveau. 25 juin 2009.

15. POHL J-B, NOVELL S, CAVALLINI J-L. Sauvetage au combatde deuxième niveau et médicalisation de l’avant.Médecine et Armées. 2011; 39 (4) : 303-9.

16. DPMO. Référentiel de formation pour l’enseignement dusauvetage au combat. EVDG. N° 309 du 30 mars 2012.

17. ASENCIO Y, PRUNET B, BORDES J, KAISER E. Hémostases


VOL.87/1


préhospitalière : de l’expérience des militaires à la pra-tique civile. Réanoxyo. 2010; 26 (2) : 45-9.

18. SAMY J, LEMARIE D, CHINELLATO M. Médicalisation del’avant en Afghanistan : à propos de 22 blessés au combatpar agent pénétrant pris en charge durant « PAMIRXXIII »au sein de la Task Force « ALTOR ». Médecine et Armées.2011; 39 (4) : 293-302.

19. PRECLOUX P, BÉREND M, PETITJEANS F, LAMBLIN A,LOHÉAS D, WEY P-F et al. Evolution de la stratégie deprise en charge des blessés de guerre au rôle 1. Conceptspédagogiques et intérêt d’un registre des soins d’urgenceau combat. Médecine et Armées. 2011; 39 (5) : 387-93.

10. ANDREW P, DAVID G, JEAN A, ADEN J, LORNE H.Tranexamic Acid for trauma patients : a critical review ofthe literature. J Trauma. 2011; 71 (1) : S9 – S14.

11. SHAKUR H, ROBERTS I, BAUTISTA R, CABALLERO J, COATS T,DEWAN Y et al. Effects of tranexamic acid on death, vascu-lar occlusive events, and blood transfusion in traumapatients with significant haemorrhage (CRASH-2) : a rando-mised, placebo-controlled trial. Lancet 2010; 376 : 23 – 32.

12. FONTAINE B, GENTILE A, FRANCOIS N, KEARNS K, CRUCM, FRISCTH N et al. Analgésie du blessé de guerre auniveau du rôle 1 : peut on mieux faire ? Réanoxyo. 2010;26 (2) : 36-7.

13. SFAR. Antibioprophylaxie en chirurgie et médecine inter-ventionnelle (patients adultes). Actualisation 2010; 17.

14. LAVILLUNIÈRE N, LEIFFLEN D, ARVERS P. Stress et santé autravail chez les sapeurs-pompiers de paris. Réanoxyo 2009;25 (3) : 90-3.

15. JEHEL L, LOUVILLE P, PATERNITI S, BAGUIER S, CARLI P.Retentissement psychologique du stress professionneldans un SAMU européen. J Européen Urgences 1999; 4 :157-64.

16. De STABENRATH O, PAQUIN S, JOST D, FUILLA C. Une nou-velle approche de la médicalisation de l’avant : les trou-bles urbains et les grandes manifestations. Réanoxyo.Mars 2008; 22:22.

17. PLANCHET M. Attaque du 20 janvier 2012, plan mascal.Actu santé. juillet septembre 2012; 128 : 19.

VOL.87/1


119TH AMSUS ANNUAL MEETING

WALTER E. WASHINGTON CONVENTION CENTER

WASHINGTON DC, U.S.A.

2-5 DECEMBER, 2014

www.amsusmeetings.org


chaîne d’évacuation car les délais sont capitaux et lesouci permanent du médecin sera de les réduire. Lemaillage sanitaire et la régulation médicale en Francerendent bien différente la prise en charge primairetype SAMU même en zone rurale (ici élongation deplus de 5 h). L’importance de cet isolement condition-nera l’attitude thérapeutique adoptée qui pourra doncêtre différente pour un même blessé (autotransfusion,ventilation mécanique…).

Alerte et moyens de communicationIls revêtent en opération une importance majeure. Enraison des délais, le message d’alerte doit être donné leplus rapidement possible après une évaluation rapidede la gravité : dans ce cas clinique, elle est déclenchéeaprès les deux garrots et avant tout le reste. Lademande de décollage de l’hélicoptère est faite au chefde section qui dans le même temps continue à gérer lecombat. La transmission des informations médicales nedoit pas être négligée. Ici 3 médecins différents ont suivice blessé avant son arrivée sur la table d’opération.

Les moyens modernes de communication (Thuraya,Irridium, Inmarsat) permettent aujourd’hui de pouvoirtransmettre des bilans aux rôles 2 ou 3 assez facilement.

Le stressIl est un facteur majeur dans ce type d’engagement. Ilest à prendre en compte car en plus d’une prise encharge d’un blessé grave, facteur anxiogène classiqueconnu des médecins urgentistes14, 15, se rajoute le stressdu combat (tir, nuit, extraction sous le feu). Pour cetteintervention, ce fut donc un coup de couteau, heureu-sement sans gravité, qui fut l’expression iatrogéniquede cet environnement stressant !

La gestion de ces situations peu fréquentes et horsnormes, nécessite une préparation particulière quipasse par un entraînement militaire minimum et uneformation médicale adaptée (CITERA, MEDICHOS). Lesdifférents thèmes joués avec une simulation haute-fidélité et/ou des blessés grimés permettent, avec lagestion des équipes en situation de crise (crew res-source management), l’acquisition d’un savoir-être. Ils’agit d’une prise de conscience individuelle. En effettout jeune médecin qui choisit cette carrière militairedoit aussi s’y préparer personnellement, Ce type d’évé-nement stressant peut arriver aujourd’hui subitementen dehors de tout contexte de combat, comme ce fut lecas plusieurs fois en Afghanistan avec des attentats sui-cides contre nos soldats16, 17 mais aussi lors de fait diversde notre société moderne (fusillade familiale, sur deslieux publics, règlement de compte…).

Il faut enfin noter l’importance, singulièrement dansles petites unités, de la relation entre l’équipe médicaleet les militaires sur la gestion du stress. Une confiancemutuelle s’installe au fil des entraînements, de la vie encampagne. Cette situation peut amener une contraintesupplémentaire pour le médecin. Dans ce contexte,c’est la prise en charge d’un camarade de combatquand ce n’est pas un ami qu’il doit gérer. Au premiercoup d’œil le médecin a saisi la gravité de la situation

et cela peut jouer négativement sur sa réactivité (stu-peur) alors que le blessé le regarde et lui fait confiance.Il s’ensuit une reconnaissance particulière que l’onretrouve peu souvent après une prise en charge enmilieu civil. Dans notre histoire, après bientôt 7 ans, ladate anniversaire du 1er décembre est toujours l’occa-sion d’un appel ou d’un mail mutuel entre le blessé etle médecin.

CONCLUSION

La prise en charge d’un blessé de guerre tel qu’elle estenseignée dans le service de santé des armées impliquedifférents intervenants : le camarade de combat (SC1),l’auxiliaire sanitaire (SC2) puis l’infirmier et le médecin(SC3). Cette chaîne hautement qualifiée a permis desauver de très nombreux blessés lors des derniers enga-gements. Elle progresse chaque année grâce au retourd’expérience des équipes médicales et à la mise enplace de nouveaux matériels et techniques validésannuellement par un comité. Mais l’environnement decombat dans lequel a lieu cette prise en charge rendson enseignement difficile et reste propre à engendrerdes actions ou un comportement inadapté. C’est doncbien au travers d’un entraînement physique, militaire,intellectuel et psychologique régulier et rigoureux que lemédecin d’unité doit se préparer pour répondre présentle jour « J ».

RESUME

A travers un cas clinique de prise en charge d’un blesséde guerre par hémorragie massive, nous revenons à lafois sur la gestion en milieu militaire de ce type de bles-sure et sur l’aspect particulier que revêt cet environne-ment de combat. Le stress intense généré lors d’unaccrochage, peut entraîner, outre des réactions inadap-tées, des gestes iatrogènes à l’origine d’une errancediagnostic ou de questions de la part des intervenantsultérieurs au cours de la chaîne d’évacuation.

BIBLIOGRAPHIE

11. Référentiel de formation au sauvetage au combat de pre-mier niveau. CISAT.2009.

12. ROUVIER B, PONS F. Traumatismes balistiques graves.Urgences et réanimation en milieu militaire. Arnette1999:31-50.

13. MARTINEZ JY, PUIDUPIN M, PRECLOUX P, KLACK F, TURC J,ESCARMENT J. les enjeux de la prise en charge des blessésdes conflits actuels. Réanoxyo. 2009; 25 (2) : 42-5.

14. INSTRUCTION N° 340143/DEF/RH-AT/PMF/DS/32 - N° 9386/DCSSA/RH/PF relative à la formation des sauveteurs aucombat de deuxième niveau. 25 juin 2009.

15. POHL J-B, NOVELL S, CAVALLINI J-L. Sauvetage au combatde deuxième niveau et médicalisation de l’avant.Médecine et Armées. 2011; 39 (4) : 303-9.

16. DPMO. Référentiel de formation pour l’enseignement dusauvetage au combat. EVDG. N° 309 du 30 mars 2012.

17. ASENCIO Y, PRUNET B, BORDES J, KAISER E. Hémostases


VOL.87/1


préhospitalière : de l’expérience des militaires à la pra-tique civile. Réanoxyo. 2010; 26 (2) : 45-9.

18. SAMY J, LEMARIE D, CHINELLATO M. Médicalisation del’avant en Afghanistan : à propos de 22 blessés au combatpar agent pénétrant pris en charge durant « PAMIRXXIII »au sein de la Task Force « ALTOR ». Médecine et Armées.2011; 39 (4) : 293-302.

19. PRECLOUX P, BÉREND M, PETITJEANS F, LAMBLIN A,LOHÉAS D, WEY P-F et al. Evolution de la stratégie deprise en charge des blessés de guerre au rôle 1. Conceptspédagogiques et intérêt d’un registre des soins d’urgenceau combat. Médecine et Armées. 2011; 39 (5) : 387-93.

10. ANDREW P, DAVID G, JEAN A, ADEN J, LORNE H.Tranexamic Acid for trauma patients : a critical review ofthe literature. J Trauma. 2011; 71 (1) : S9 – S14.

11. SHAKUR H, ROBERTS I, BAUTISTA R, CABALLERO J, COATS T,DEWAN Y et al. Effects of tranexamic acid on death, vascu-lar occlusive events, and blood transfusion in traumapatients with significant haemorrhage (CRASH-2) : a rando-mised, placebo-controlled trial. Lancet 2010; 376 : 23 – 32.

12. FONTAINE B, GENTILE A, FRANCOIS N, KEARNS K, CRUCM, FRISCTH N et al. Analgésie du blessé de guerre auniveau du rôle 1 : peut on mieux faire ? Réanoxyo. 2010;26 (2) : 36-7.

13. SFAR. Antibioprophylaxie en chirurgie et médecine inter-ventionnelle (patients adultes). Actualisation 2010; 17.

14. LAVILLUNIÈRE N, LEIFFLEN D, ARVERS P. Stress et santé autravail chez les sapeurs-pompiers de paris. Réanoxyo 2009;25 (3) : 90-3.

15. JEHEL L, LOUVILLE P, PATERNITI S, BAGUIER S, CARLI P.Retentissement psychologique du stress professionneldans un SAMU européen. J Européen Urgences 1999; 4 :157-64.

16. De STABENRATH O, PAQUIN S, JOST D, FUILLA C. Une nou-velle approche de la médicalisation de l’avant : les trou-bles urbains et les grandes manifestations. Réanoxyo.Mars 2008; 22:22.

17. PLANCHET M. Attaque du 20 janvier 2012, plan mascal.Actu santé. juillet septembre 2012; 128 : 19.

VOL.87/1


119TH AMSUS ANNUAL MEETING

WALTER E. WASHINGTON CONVENTION CENTER

WASHINGTON DC, U.S.A.

2-5 DECEMBER, 2014

www.amsusmeetings.org


By I.M. SAMOKHVALOV❶, A.N. PETROV❷ and V.A. REVA❸. Russian Federation

Igor M. SAMOKHVALOV

Russian System for Temporary Control of ExternalHemorrhage in Combat-related Major ExtremityVascular Injuries: Realities and Prospects.*

Colonel MC (Ret) Igor M. SAMOKHVALOV was born in 1954.In 1977, he graduated from Kirov Military Medical Academy, St.-Petersburg, Russia.

He served as general duties doctor and as surgeon in Pskov Guard AirborneDivision (1977-1981). After war surgery residency course (1981-1984) he attended

the 10 ICMM International Advanced Courses for young military doctors (Finland, 1983)and then served as a teacher of surgery, Associated professor, Deputy Head at the War Surgery Departmentof Kirov Military Medical Academy. He has deployed as surgeon in operations (Afghanistan 1980, 1987-88,the North Caucasus 1994-1995), and in Earthquake (Armenia, 1988).Since 2007 to presence he is the Head of the War Surgery Department and Clinic (1st Level Trauma Center).In 2009 he retired from military service but at the same time became Chief Surgeon of the Russian ArmedForces and Senior polytrauma specialist at St.-Petersburg Dzhanelidze Research Institute of EmergencyMedicine.He is PhD (1985), Doctor of Science (1995), Professor of Surgery (1998), Honored Physician of RussianFederation, member of European Society for Vascular Surgery (ESVS) and the Ambroise Pare InternationalMilitary Surgery Forum (APIMSF), author of more than 400 scientific works. His research interests includewar surgery, trauma surgery, vascular trauma, emergency and disaster medicine, surgical education, historyof surgery.


ARTIC

LES

ARTIC

LES

RESUME

Organisation russe de contrôle des hémorragies externes dans les blessures vasculaires graves desextrémités chez le blessé de guerre: réalités et prospective.

Dès la seconde guerre mondiale, avec l’apparition des soins préhospitaliers aux combattants, le contrôle des hémorragies venaitau premier rang des préoccupations, les systèmes les plus utilisés étant les garrots. Par la suite, les procédures évoluaient avecl’apparition de nouvelles techniques et certaines d’entre elles, mises au point par des chirurgiens russes et oubliées depuis, trouvaientde nouveaux développements, y compris dans les pays étrangers. La priorité est habituellement donnée aux techniques de contrôledes hémorragies qui permettent de conserver le membre blessé (agents hémostatiques locaux, pansements compressifs, clamps etc.)et certaines innovations comme le garrot à ultrasons semblent prometteuses. Sur le champ de bataille, le garrot reste la méthodede choix en cas d’amputation de membre et de blessure proximale (notamment de la cuisse). Dans les autres cas, en fonction del’intensité du saignement, on utilise les pansements compressifs ou les agents hémostatiques. La modernisation des services desanté s’est accompagnée de l’enrichissement de l’arsenal des techniques d’hémostase en amont de l’hôpital avec des méthodesépargnant les membres introduites dans les algorithmes de soins préhospitaliers des blessures vasculaires graves provoquées parles armes de guerre. Nous présentons un de ces nouveaux dispositifs.

VOL.87/1

KEYWORDS: Extremity vascular injury, Combat casualty care, Prehospital care, Hemorrhage control, Tourniquets.MOTS-CLÉS : Blessures vasculaires des extrémités, Soins aux blessés de guerre, Soins préhospitaliers, Contrôle deshémorragies, Garrots.

“Numerous people die just because our soldiers andeven officers are not able to stop bleeding in limb inju-ries. Many are taken aback at the sight of blood spur-ting from the wound, and try to evacuate a bleedingcasualty to the rear hastily… It is too bad that not onlysoldiers and officers, but some corpsmen, combat

nurses and even paramedics are afraid of bleeding.”A.A. Vishnevskiy. Diary of a Surgeon.

The Great Patriotic War, 1941-1945.

By a System for Temporary Control of ExternalHemorrhage in Combat-related Major Extremity

External Hemorrhage_SAMOKHVALOV_Mise en page 1 21/03/14 11:38 Page1

By I.M. SAMOKHVALOV❶, A.N. PETROV❷ and V.A. REVA❸. Russian Federation

Igor M. SAMOKHVALOV

Russian System for Temporary Control of ExternalHemorrhage in Combat-related Major ExtremityVascular Injuries: Realities and Prospects.*

Colonel MC (Ret) Igor M. SAMOKHVALOV was born in 1954.In 1977, he graduated from Kirov Military Medical Academy, St.-Petersburg, Russia.

He served as general duties doctor and as surgeon in Pskov Guard AirborneDivision (1977-1981). After war surgery residency course (1981-1984) he attended

the 10 ICMM International Advanced Courses for young military doctors (Finland, 1983)and then served as a teacher of surgery, Associated professor, Deputy Head at the War Surgery Departmentof Kirov Military Medical Academy. He has deployed as surgeon in operations (Afghanistan 1980, 1987-88,the North Caucasus 1994-1995), and in Earthquake (Armenia, 1988).Since 2007 to presence he is the Head of the War Surgery Department and Clinic (1st Level Trauma Center).In 2009 he retired from military service but at the same time became Chief Surgeon of the Russian ArmedForces and Senior polytrauma specialist at St.-Petersburg Dzhanelidze Research Institute of EmergencyMedicine.He is PhD (1985), Doctor of Science (1995), Professor of Surgery (1998), Honored Physician of RussianFederation, member of European Society for Vascular Surgery (ESVS) and the Ambroise Pare InternationalMilitary Surgery Forum (APIMSF), author of more than 400 scientific works. His research interests includewar surgery, trauma surgery, vascular trauma, emergency and disaster medicine, surgical education, historyof surgery.


ARTIC

LES

ARTIC

LES

RESUME

Organisation russe de contrôle des hémorragies externes dans les blessures vasculaires graves desextrémités chez le blessé de guerre: réalités et prospective.

Dès la seconde guerre mondiale, avec l’apparition des soins préhospitaliers aux combattants, le contrôle des hémorragies venaitau premier rang des préoccupations, les systèmes les plus utilisés étant les garrots. Par la suite, les procédures évoluaient avecl’apparition de nouvelles techniques et certaines d’entre elles, mises au point par des chirurgiens russes et oubliées depuis, trouvaientde nouveaux développements, y compris dans les pays étrangers. La priorité est habituellement donnée aux techniques de contrôledes hémorragies qui permettent de conserver le membre blessé (agents hémostatiques locaux, pansements compressifs, clamps etc.)et certaines innovations comme le garrot à ultrasons semblent prometteuses. Sur le champ de bataille, le garrot reste la méthodede choix en cas d’amputation de membre et de blessure proximale (notamment de la cuisse). Dans les autres cas, en fonction del’intensité du saignement, on utilise les pansements compressifs ou les agents hémostatiques. La modernisation des services desanté s’est accompagnée de l’enrichissement de l’arsenal des techniques d’hémostase en amont de l’hôpital avec des méthodesépargnant les membres introduites dans les algorithmes de soins préhospitaliers des blessures vasculaires graves provoquées parles armes de guerre. Nous présentons un de ces nouveaux dispositifs.

VOL.87/1

KEYWORDS: Extremity vascular injury, Combat casualty care, Prehospital care, Hemorrhage control, Tourniquets.MOTS-CLÉS : Blessures vasculaires des extrémités, Soins aux blessés de guerre, Soins préhospitaliers, Contrôle deshémorragies, Garrots.

“Numerous people die just because our soldiers andeven officers are not able to stop bleeding in limb inju-ries. Many are taken aback at the sight of blood spur-ting from the wound, and try to evacuate a bleedingcasualty to the rear hastily… It is too bad that not onlysoldiers and officers, but some corpsmen, combat

nurses and even paramedics are afraid of bleeding.”A.A. Vishnevskiy. Diary of a Surgeon.

The Great Patriotic War, 1941-1945.

By a System for Temporary Control of ExternalHemorrhage in Combat-related Major Extremity


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The Evolution of Point-of-Wounding Hemorrhage Control

Vascular Injuries we mean a set of measures performedfrom the point of injury to the delivery of patient tothe operating room to prevent life-threatening seque-lae, provide prophylaxis against complications, and,eventually, save his life and preserve the function of hislimb. The term “system” is used as 1) the indicator ofphase-by-phase increase in the amount of care delive-red following first aid (FA), and 2) the reference to therequirement of provision of pre-hospital care (PHC) notlimited by use of a single method of temporary hemor-rhage control (THC), even if the method is effective.The system involves the proper anesthetic care, fluidand blood resuscitation, early antibiotic prophilaxy,protection against reperfusion injuries, and early measuresto save a severely injured limb.

DEVELOPMENT OF RUSSIANPRE-HOSPITAL CARE SYSTEM

FOR CONTROL OF EXTERNAL HEMORRHAGE

Numerous methods and devices have been developedto control external hemorrhage, ranging from the sim-plest methods (packing and local compression of thebleeding wound) to rather complex devices (compres-soriums and pneumatic cuffs) introduced in the 19th

and 20th centuries. However, the complex devices havenot proved valuable in the combat setting because ofthe battlefield requirement for as simple, reliable andconvenient means as possible. In the Russian Army, ithas been customary to apply tourniquet to stop mas-sive arterial hemorrhage. The domestic guidelines ofthe 1930s and 1940s considered the application of atourniquet use as the basic (and only) prehospitalmethod of THC (MTHC).

During World War II, authorized and makeshift tourni-quets were the most (62.7%) and the least (3%) fre-quently applied MTHC, respectively, whereas a pressuredressing and other MTHC (including a tight woundpacking) were applied in 27.6% and 6.7% of cases, res-pectively1. Primary hemorrhage was stopped by mili-tary medical personnel operating within proper mili-tary district and by soldiers and officers through selfand buddy aid. Aside from rubber tourniquets, a clothRed Army Sanitary Research and Test Institute tourni-quet of 1934 (Fig. 1) was also used. This cloth unit hadthe benefit of some adjustability of tourniquet pressurelevel, compared to the Esmarch rubber tourniquet.However, it had some drawbacks related to unreliablefixation of its buckle and inconvenience in use1, 2.

The MTHC developed in the Soviet Union soon afterWorld War II have failed to find wide acceptance,although some of them were rather interesting (theylooked like modern clamps designed for hemorrhagecontrol)3.

During the war in Afghanistan (1979-1989), despite theappearance of a number of new devices, no radicalchanges in prehospital care (PHC) of casualties withcontinued bleeding took place, when compared toWorld War II. The MTHC �individual dressing packets

(2 packets per man) and rubber tourniquets (1 pieceper 5-10 men) � were involved into the standard issuemedical materiel sets issued to servicemen before theywent to combat actions4. A tourniquet was applied inover half of the extremity arterial injuries1, 2.

Because a standard issue rubber tourniquet has a num-ber of drawbacks, and above all, marked tissue dama-ging effect, during the operation in Afghanistan (1979-1989), a group of domestic surgical scientists, V.A. Popovwith colleagues from Kirov Military Medical AcademyCombat-related Surgical Trauma Research Laboratory,tested a System of Care for Combat-related MajorExtremity Vascular Injuries comprising the following5.

1. First Aid (FA).

Windlass-and-strap tourniquets presewn into the mili-tary uniform. A windlass-and-strap tourniquet consis-ting of a wooden or plastic stick and sewn-in strap cor-responding to the circumference of the sleeve or trou-ser leg was offered to be presewn into the military uni-form at the level of the upper third of the arm or thigh.In extremity vascular injury, presewn windlass-and-strap tourniquets provided the casualty with an oppor-tunity to easily stop bleeding with his hand andwithout assistance. Availability of such presewn wind-lass-and-strap tourniquets has been reported to ensureTHC in 9 casualties in the combat setting5.


VOL.87/1

� Colonel (Ret.),Honoured Physician of the Russian Federation,Chief Surgeon of the Russian Army,Professor and Chair of War Surgery Department,Kirov Military Medical Academy, Saint-Petersburg, Russia.

� Colonel,Associate Professor at War Surgery Department,Kirov Military Medical Academy, Saint-Petersburg, Russia.

� Captain,Assistant Professor at War Surgery Department,Kirov Military Medical Academy, Saint-Petersburg, Russia.

* Presented at the ICMM International Conference on Military Medicine,St-Petersburg, Russian Federation, 27th of October to 1st of November 2013.

Figure 1: Tourniquets. A Red Army Sanitary Research andTest Institute tourniquet used during World War II, now

exhibited at the museum of the Military Medical AcademyWar Surgery Department (left), Combat Application

Tourniquet™ (CAT) (center), and Special OperationsForces Tactical Tourniquet™ (SOFTT) (right).


2. Prehospital paramedic care (PMC).

Tourniquets with graduated compression. To reduceunderlying soft tissue pressure, a woven elastic band(width, 3 cm; length, 130 cm) made of rubberized syn-thetic fabric was offered. Dynamometer was used toensure the correct ratio of tensile and pressing forceswhen marking the tourniquet. A round stamp with thecentered digit denoting the specified tensile force (kg)for each complete turn of a tourniquet was used to getthe specified (10-15 cm) mark-to-mark intervals for stan-dard graduated tourniquet pressure (300-350 mm Hg)(Fig. 2). Correct application of this tourniquet requiresstretching the band until ellipse-to-circle transformationof the marks shows the achievement of a specified pres-sure value. In case of initial rectangular marking, stret-ching of t he band resulted in rectangle-to-square trans-formation.

Such a tourniquet with graduated compression couldbe used just at the point of injury, if indicated, or ins-tead of pre-applied windlass-and-strap tourniquet.Having applied this tourniquet in 10 casualties withintensive external hemorrhage in Afghanistan, theauthors of above-mentioned system managed toachieve reliable hemostasis5.

3. Emergency medical care (EMC).

Percutaneous ligation of the vascular bundle5-7.

This hemorrhage-control technique consists in passinga ligature through the soft tissues of the middle thirdof the thigh by N. Fomin6 or inguinal region by S.Tkachenko et al.7 by means of special needles (Fig. 3).However, this technique requires perfect knowledge oflimb anatomy and good practical skills from the medics,and, therefore, is hardly applicable to the combat set-ting. Besides that, anatomy of the injured extremities isalways changed.

Thus, already during the operation in Afghanistan, pro-posals were formulated to develop the prehospital caresystem for casualties with major extremity vascularinjuries. However, these interesting developments have

failed to expand the arsenal of PHC because of imper-fection of technical solutions and low number of obser-vations on their practical use, which eventually provi-ded no reasons for revision of measures for THC.

During armed conflicts in the Northern Caucasus (1994-1996 and 1999-2002), about a twofold decrease in therate of tourniquet use took place, although the per-centage of casualties having this device as a medicalpersonal protective equipment increased from almost50% to 100%. This indicates both the improvement inbasic knowledge of servicemen and adequateness oftheir practical skills in use of different MTHC.

MODERN ALGORITHM OF PREHOSPITAL CAREWITHIN A SETTING OF MILITARY CONFLICT

When providing any type of medical care, control of conti-nued external hemorrhage is an absolute priority5, 8-9. It isthe timely and adequate care provided at the prehospitalphase and first phases of medical evacuation that are cru-cial for the outcome of treatment of casualties with majorextremity vascular injuries. Any mistakes, if made at theseearly phases, in most cases are failed to be corrected sub-sequently even with high-quality medical care.

The main features determining the specificity of PHC inmodern combat are as follows10:• Wide variation in the combat operational modes(from urban combat to large-scale offensive combatraiding)• Variation in the medical and geographic conditionsof the region• Frequent difficulties with early evacuation of combatcasualties due to various (organizational, tactical andclimatic) reasons• Increase in the share of severe and very severe com-bat traumas, and• Inadequate skills of servicemen in providing treat-ment for THC.The basic MTHC and algorithms of PHC of vascular inju-ries are described in numerous guidelines; however, thecare system for this category of casualties is beingcontinuously advanced taking into account the intro-duction of new and new MTHC.


VOL.87/1

Figure 2: Tourniquet with graduated compression.The band is stretched to get ellipse-to-circle transformation

of the marks. The tourniquet is applied to the upper thirdof the forearm.

Figure 3: Surgical set used to perform the percutaneousligation of the femoral vascular bundle.


First Aid

Elementary FA measures aimed at control of continuedhemorrhage are the mainstay of life-saving treatmentof combat casualties. In a massive hemorrhage, buddiesrather often try to compress the casualty wound in achaotic way using the methods which are usually inef-fective, such as applying manual pressure over thewound covered with clothing or compressing the arteryproximally to the wound. In other cases, even in a sligh-test wound bleeding, they try to apply a tourniquethastily because of their agitated state.

To avoid loss of time and ensure effective THC whenproviding the FA, the following procedure must be fol-lowed:1. Remove the casualty’s clothing and footwear toexpose the wound (push or cut away the clothingaround the wound).2. Clothing or any fragments or bullets stuck to thewound should be left alone.3. Use the proper method of THC based on the amountof bleeding and location of the wound.

Taking into account the available standard issue perso-nal medical materiel, we find it expedient to note thefollowing methods of THC with regard to FA provisionin the modern combat setting: application of 1) pres-sure dressing, 2) tourniquet, and 3) local hemostaticagents (LHAs).

According to N. Pirogov11, it can be said definitely whe-ther the bleeding is arterial or venous only when thesurgeon observes the bleeding personally, or it hasstopped recently and the patient has not yet becomeweakened greatly. Taking this into account, it is notexpedient to differentiate these types of bleeding withregard to FA provision. Certainly, capillary bleedingfrom small dermal and muscular vessels must be diffe-rentiated from a life-threatening, massive hemorrhage,the former requiring application of a common asepticdressing.

Isolated major venous injury, if a hole in the vein issmall and venous hypertension is present (e.g., secon-dary to the vein compression by a bone fragment proxi-mal to the injury site), may result in massive hemor-rhage. Characteristic feature of venous bleeding is thecontinuity of the spurt having dark-cherry to blackcolor. Here the first responder’s primary focus should beon the amount of ongoing bleeding. Because theassessment of the amount of external bleeding isalways partly subjective, in present-day conditions,greater use should be made of LHAs, which, being ofrather effective and less damaging action, are actuallyuniversal means for any type of bleeding.

In slight and mild bleeding from the wound, a pressuredressing is indicated. When applied correctly, it can alsostop the spurting hemorrhage from the lower leg,upper arm and forearm wounds; however, unlike itsapplication in junctional areas (i.e., axillary, inguinaland gluteal regions), the application in blast injuries is

inexpedient. To apply a pressure dressing, special elas-tic bandages are used, e.g., that of individual dressingpacket PPI-01 (Russia) or the Emergency Bandage™(the USA and Israel).

However, with account of specific conditions ofcasualty care on the battlefield, inadequate militarymedical skills of servicemen, and difficulties in imple-mentation of all the modern principles of the systemfor THC in the combat setting, the tourniquet is still thebasis of algorithm for the FA12, and, in this case, has thelife-saving function. In the combat setting, if appliedcorrectly and promptly, the tourniquet will save morelives than ineffective attempts to apply various dres-sings and LHAs. Therefore, when providing FA in 1)traumatic limb amputation and 2) massive thigh orupper arm wound hemorrhage, tourniquet applicationis the method of choice.

When providing FA, the rules of application of theEsmarch – Langenbeck rubber band tourniquet are asfollows:• Select the application site. It should be proximal andas close as possible to the wound.• Place the tourniquet upon the clothing or soft pad.• To apply the tourniquet, turn it once to controlhemorrhage, avoiding overcompression of the limb.Subsequent turns should maintain compression. Withthis done, secure the tourniquet in place.• Ensure the tourniquet is clearly visible. DO NOT coverit.• Note the time of application.• Administer an analgesic agent from an individualfirst-aid kit.• To immobilize the limb for transportation, apply atriangular bandage sling or a jacket flap sling to theinjured upper limb, and fix the injured lower limb tothe healthy limb.

Applied very often during World War II in RussianArmy, the Esmarch elastic tourniquet has been usingfor many years in military and civilian setting. This tour-niquet is highly effective but has negative effects dueto its small width (1 to 1.5 cm stretched out). Whiletourniquet application is the treatment method ofchoice for massive hemorrhage in compressible extre-mity injuries, LHAs play a role in the treatment of inju-ries to junctional regions, because tourniquet applica-tion in a figure-of-eight fashion in inguinal and axillaryregions is often ineffective.

Paramedic Care

In PMC, if compared with FA, the arsenal of availableMTHC, conditions for the provision of care, and(because the care provider is the paramedic) care qua-lity standards are somewhat superior. It is the parame-dic – the medically educated person – that should assessthe correctness of application and efficiency of thetourniquets applied earlier and remove the conse-quences of improper provision of FA. If he or she findsit properly applied and hemostasis effective, removal ofthe tourniquet is inexpedient.


VOL.87/1


Application of LHAs may be singled out as a high-prio-rity MTHC in PMC. “Hemostop”, a synthetic zeolite-based LHA was developed by a group of Russian resear-chers in 2009, and introduced into current standardissue FA kits, medical bags, and medical materiel sets ofthe Russian Armed Forces. Its mechanism of action issimilar to that of QuikClot™ with the same adverseeffects including an increase of local tissue temperature.Experimental studies in sheep and rabbits as well as cli-nical studies have shown high efficacy of Hemostop.However, application of Hemostop, in spite of its appa-rent simplicity, requires proper practical skill and anato-mic knowledge, mechanism of action of the agent, andvariations in its use depending on the wound character.

Application of finger compression over proxima l arterialpressure points and direct compression of the woundcannot be considered reliable prehospital MTHC underthe austere combat environments. In massive hemor-rhage, searching for proximal arterial pressure pointsand ineffective attempts of wound compression mayresult in irreversible blood loss. These methods are justi-fied only when used as those preparing for applicationof the pressure dress ing, LHAs and tourniquet.

Currently, taking into account the available preparedpersonnel and standard issue MTHC, the followingalgorithm for control of massive hemorrhage in PMC isoffered:1. Put pressure on the wound or compress the arteryproximally to the wound.2. Apply Hemostop according to the following proce-dure (Fig. 4):

• Use a gauze bandage to clean the blood from thewound.

• Open the package and pour some powder agentinto the bleeding site.

• Place a cotton-and-gauze pad or a piece of anycloth over the powdered agent and apply direct pres-sure during 5-7 minutes.

• Apply a pressure dressing over the pad.3. Apply the tourniquet, if the wound bleeding fails tostop.

After application of LHAs, place a provisional tourni-quet proximally to the wound and leave it untied, and,if renewed bleeding occurs, apply it as early as possible.Anesthesia and immobilization for transportation mustbe also performed.

In hypotension (systolic blood pressure less than 90 mmHg), blood loss replacement by intravenous infusion ofcrystalloid is the next most important PMC measureafter control of hemorrhage. To provide for infusion ofplasma substitute, either a plastic catheter of at least18G should be installed for the period of transporta-tion to the EMC site, or intraosseous infusion of at least800 ml should be given during that period.

Emergency Medical Care

EMC is the main type of PHC10. In modern military conflict,the site of EMC provision placed as close as possible to the

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Figure 4: Hemostop application procedure. (a) Clear theblood clots and foreign matter from the wound. (b) Poursome powder agent as close as possible to the source of

bleeding. (c) Place a cotton-and-gauze pad over the powde-red agent and apply manual pressure over the wound during

5-7 minutes. (d) Apply a pressure dressing over the pad.

D

C

B

A


battlefield, and is used mostly to prepare the casualtiesproperly prior to evacuation13. This is especially importantbecause, in modern local wars, the possibility of early airmedical evacuation directly to the site of special surgicalcare provision (tertiary care military hospital) has a deci-sive influence on the quality of provided care10, 12, 13.

After arrival to the site of EMC provision, casualties withcontinued bleeding, blood-soaked dressings, and appliedtourniquet are the first to be directed to wound-dressingpoint to stop bleeding, check the tourniquet status, andcontinue the infusion of crystalloid. For intravenous infu-sions, the cubital vein with pre-inserted peripheral catheterand external jugular vein may used, and, if the anesthetistis on the staff of a military unit, either the subclavian orinternal jugular vein may be catheterized; saphenous veincutdown is performed if other options are unavailable.

Check of the status of the applied tourniquet(“Tourniquet Control”) is the measure used to determinethe feasibility of its further application and consider itssubstitution by a more limb-sparing method of THC. Thecheck is performed as follows: after administration ofanesthesia, the dressing is removed from the wound, anassistant compresses the artery proximally to the site oftourniquet application, and the tourniquet is loosened. Ifboth external bleeding and signs of damage to majorvessels are absent, the tourniquet is removed. When indoubt, a pressure dressing is applied to the wound, whe-reas the tourniquet is left untightened on the limb. Ifrenewed bleeding occurs, limb-sparing hemostaticmethods must be used. However, if these methods fail tostop bleeding, the tourniquet is reapplied for life salvage.

In casualties presenting with signs of irreversible ischemia(muscle contracture), the tourniquet must not be remo-ved. At the EMC phase, the MTHC are as follows:• to put a hemostat over the visible vessel in the woundfollowed by vessel ligation or, if impossible, by taping thehemostat to the limb with gauze.• tight wound packing (August Bier’s method14).• LHAs.• a pressure dressing.• transcutaneous balloon catheter tamponade15.

Tight wound packing is performed as follows. Tight bot-tom-to-top wound packing with gauze pads and tam-pons is performed while delivering the pads to theapproximate location of the source of bleeding; thendeep interrupted dermal subcutaneous sutures are pla-ced over the dressing pads, with the number of suturesdepending on the severity of damage to the dermis.

In some cases, if the method initially used fails to solvethe problem, medics have to combine at least two MTHC,e.g., application of a hemostat in the wound followed bytight wound packing, or application of LHAs followed bya tight wound packing.

Because the transcutaneous balloon catheter tamponaderequires special theoretical knowledge and practical skilland availability of either a Foley catheter or standard

issue special equipment, it should not be used in the pro-vision of FA or PMC. Compression of the artery to thebone or to adjacent tissues by the inflated balloon maybe used if a flesh wound presents with continued massivehemorrhage from the brachial artery or resulted fromthe injuries of the arteries of adjacent regions (the sub-clavian and axillary arteries and femoral artery bifurca-tion). Blood delivery through a catheter lumen willreflect continued bleeding, thus indicating the need forapplication of another MTHC. If a deep narrow wound(i.e., a stab wound) is present, and a deep source of blee-ding is suspected, it is extremely difficult to use the trans-cutaneous balloon catheter tamponade because of thechanges in the wound track due to tissue elasticity andheterogeneity.

MEDEVAC of casualties with major extremity vascularinjuries to the Role II and Role III medical treatment faci-lities should be performed after application of the limb-sparing MTHC, including, in particular, such moderndevices as pneumatic tourniquets and cuffs or specialadjustable clamps.

A casualty with first applied tourniquet should be eva-cuated to the next Medical Treatment Facilities (Role 3)only if his prompt delivery (within 1 to 1.5 hour) to theoperating room is possible.

Generally, at the EMC phase, when the capacity to treatseriously injured servicemen is much higher than that atthe previous phases, the methods applied for THC mayvary depending on availability of proper medical equip-ment and the skill of personnel (refer to table 1).Provision of reliable hemostasis is the key factor to betaken into account when selecting the means of THC.

This table shows that LHAs are given the highest priorityfor application in any region of the limb. It is worthnoting that the agents of this group ensure good andreliable hemostasis only when correctly applied. In adja-cent regions, transcutaneous balloon catheter tampo-nade may be also used. The greatest number of differentmeans is applicable in distal limb injuries. In proximallimb regions, application of LHAs, pressure dressing, andtight wound packing is indicated, and that of a tourni-quet is also effective. Such an approach is somewhatdifferent from that used in the US Armed Forces,where the priority is given to the first applied tourni-quet (“Tourniquet First!”), whereas LHAs are appliedonly when tourniquet application is impossible orwhen evacuation is delayed.

The flowchart of the suggested Algorithm of PrehospitalCare of Combat-Related Major Extremity Vascular Injuriesis shown in Fig. 5.

SUGGESTIONS FOR IMPROVEMENTOF THE SYSTEM FOR TEMPORARY CONTROL

OF EXTERNAL HEMORRHAGE

More than 140 years have passed since introduction ofEsmarch rubber tourniquet, and there have been


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revealed numerous drawbacks of its use and threatsto limb vitality unrelated directly to major arterialinjury. The Red (Soviet) Army adopted this tourniquetas early as in the thirties and used it throughoutWorld War II.

Moreover, the Russian Armed Forces used it in the fol-lowing wars including the most recent military conflictsof the 21th century, and it is still being used by Russianemergency teams although it has become obsolete forcurrent use. In spite of availability of models of otherdomestic devices for hemorrhage control, the Esmarch-Langenbeck rubber band tourniquet currently remainsthe only standard-issue tourniquet in the RussianArmed Forces.

While understanding that continued external hemor-rhage is the leading cause of death in the potentiallysurvivable battlefield cases, foreign developers ofmedical protective devices have been making conti-nuous advancements in the system for temporary

hemostasis8-10, 12. There are more and more new tour-niquets meeting increasingly strict requirements fordesign and strength. Table 2 provides the data relatedto comparison of current standard-issue tourniquets ofthe Russian Army and the US Army and their confor-mance, partial conformance or non-conformance tothe requirements.

The experience of local wars and armed conflicts hasshown that medical equipment issued to servicemenshould be a subject of continuous advances. This pro-gress may be achieved either by upgrade of old devicesor by the development of fundamentally new productswith novel mechanism of action.

Taking into account the forced phase-by-phase charac-ter of care to casualties with external hemorrhage,there is a requirement for improvement of means andmethods of THC related to not only FA and PMC, butalso to EMC phase; moreover, casualty-friendly MTHCshould be applied during EMC phase. For the purposeof development of the FA, in cooperation with com-pany “Medplant” we created a new tourniquet (PatentApplication No. 2013143691, 27.09.2013), which is nottested in combat-related injuries yet. This simple tour-niquet is assigned for Care Under Fire. Its mechanism ofaction is similar to that of Red Army Sanitary Researchand Test Institute tourniquet and CAT™. The 4-cmwidth “Medplant” tourniquet contains a special custorto record the time of application and allows stoppingperipheral blood flow in upper and low extremities(Fig. 6).

Another company “Medtekhnika Co. Ltd” supported bythe authors of this paper produced a special electronicand pneumatic tourniquet (Patent No.2013119501-134419, 22.04.2013). This tourniquet with a workingtitle of Hemostatic Electronic-Pneumatic Tourniquet(HELP-T) provides for substantial improvement in thequality of PMC delivered (Fig. 7).

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AREA LHAS PD TWP PAC CLAMP BALLOON TOURN. PC PS

1

2

3

Notes :

1 = junctional regions, 2 = proximal limb regions, 3 = distal limb regions.

Area = anatomic application site, LHAs = local hemostatic agents, PD = pressure dressing, TWP = tight wound packing,PAC = proximal arterial compression, Clamp = application of a hemostat in the wound, Balloon = transcutaneous ballooncatheter tamponade, Tourn. = tourniquet, PC = pneumatic cuff, PS = pneumatic splint.

Effective

Not applicable

Application is problematic or of doubtful effect

Table 1: Application of means of THC depending on the location of the wound.

Figure 5: Algorithm of Prehospital Care of Combat-RelatedMajor Extremity Vascular Injuries.


The main benefits of HELP-T are as follows:1. Possibility of one-handed self-application, both forthe upper and lower extremities.


VOL.87/1

BASIC REQUIREMENTS ESMARCH RUBBER TOURNIQUET CATOUR REQUIREMENTS TO

THE PROSPECTIVE TOURNIQUET

Used as a standard issue tourniquetin the Armed Forces of

Russia USA

Minimal sufficient compression (applicationshould not lead to excessive compression)

- ± +

Minimal tissue trauma (ensured by the band,cuff or strap of more than 2.5-cm width)

- + +

Possibility of adjustment in pressure exertedon the tissues (compressing-and-loosening

cycles), i.e., possibility of periodical decreasein compression

- + +

Possibility of application in a figure-of-eightfashion in junctional regions

+ - -

Possibility of one-handed self-application - + +

Ease of (speedy) application + + +

Mechanical tourniquet strength + + +

Easy design (i.e., minimal number of parts) + + ±

Reliability of locking device ± + +

Wearing capacity + - +

Light weight ± + ±

Portability + + +

Modern material - + +

Possibility of application when the tourniquetis introduced into the uniform

- - -

Possibility to record the time of applicationon the tourniquet

- - +

Low prices + + ±

Table 2: Requirements to the modern tourniquet.

Figure 6: A new tourniquet produced by “Medplant”(Moscow, Russia).

Figure 7: HELP-T. Contour cuff with electronic control unit.


2. Possibility of inflating the tourniquet to pre-set pres-sure values (200 mm Hg and 300 mm Hg for upper andlower limbs, respectively) to minimize damage to tis-sues beneath the cuff.3. Possibility of prompt decompression by switching offthe unit.4. Width value and shape (8 cm and taper, respectively) ofthe cuff promote for even distribution of pressure to mini-mize both damage to the tissues beneath the tourniquetand painful effects.5. Electronic pumping system maintains the pre-setpressure during the total application period (at least 4hours without battery recharging).6. Audible indication of tourniquet time: the unit gene-rates an audible warning signal when the cuff inflationtime exceeds 2 hours. When discharged, the storagebattery is recharged by means of a special charger.7. Bright orange color of the cuff makes the device wellseen by medics.

The device was tested during Rubezh 2013 militarymedical field exercise performed by the staff and stu-dents of Kirov Military Medical Academy (St.-Petersburg, Russia).

In the exercise field, HELP-T was applied instead of thecurrent standard-issue elastic tourniquet. Being ratherheavy (490 g), this device was not included in individualequipment of each soldier. It was carried in the para-medic’s aid bag (backpack). In the field, HELP-T wasapplied to provide PMC immediately after wounding(Fig. 8a), whereas at the site of the medical platoon ofbattalion, paramedics applied HELP-T after removal ofpre-applied elastic or improvised tourniquet.

Shortly, HELP-T has proved to be highly efficient instopping limb circulation in all application cases. In allthe cases, HELP-T was easily applied; no failures in itsapplication have been registered during the exerciseperiod. The tourniquet display was found to contributeto user-friendliness of the device, updating the dis-played cuff air pressure value once a second and provi-ding for continuous monitoring of tourniquet time. Nobattery recharging was required. All the «wounded»servicemen have noted significantly less pain effects ifcompared to those of the standard-issue tourniquet.When applied, HELP-T did not hinder the care provi-ders of proceeding with the provision of care, movingthe casualty to safety, and performing the subsequenttransportation (Fig. 8b). Having pressed the air pressureinflation button, the combat lifesaver or paramediccould continue providing care. Although HELP-T sho-wed high efficacy and reliability during laboratoryinvestigation and field exercises, it has not been testedin real practice yet. Hopefully, this pneumatic tourni-quet with the guiding price of 125 euro will apply toprehospital military (PMC) and civilian emergencymedicine practice.

Another way to advance the means of delivering PHC isto use modern analogs of almost forgotten ancientmedical devises – “compressoriums” for stopping junc-tional and proximal limb hemorrhage. These regions

present a particular problem to the medic trying togain control of the hemorrhaging wound, and applica-tion of such devices for stopping junctional and proxi-mal limb hemorrhage may be considered a method ofchoice9,16. Modern clamps, e.g., the JETT™ (JunctionalEmergency Treatment Tool), CRoC™ (Combat ReadyClamp, Combat Medical Systems, Fayetteville, NC) andAbdominal Aortic Tourniquet™ fit to such group ofcompressoriums17-19.

By and large, application of a modern clamps producesno tissue damage effects related to that of elastic tour-niquet. Local compression of the major artery does notstop collateral circulation of the limb. In PHC, such typeof device can be successfully applied to stop continuedmassive arterial hemorrhage. Moreover, its applicationin combination with pressure dressing or tight woundtamponade for this purpose makes the two other appli-cation components definitely effective with the majorartery locally compressed. In cooperation with company“Spetsmedtekhnika Co. Ltd” we have developed a pro-totype model of such a device to control junctionalhemorrhage (Fig. 9).

Furthermore, the development of fundamentally newproducts is underway. Use of portable ultrasound devicesintegrated into the tourniquet cuff and developed under

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Figure 8: Application of HELP-T at the exercise battlefieldby a combat lifesaver during Rubezh 2013 military

medical field exercise. (a) Application of the tourniquetto the right thigh. (b) Moving the arm-injured casualty

(who has HELP-T applied) from the exercise battlefield.

A

B


the aegis of Defence Advanced Research Projects Agency(DARPA) has a great potential for achieving hemostasis20.The goal of DARPA Deep Bleeder Acoustic Coagulation(DBAC) program is to develop a noninvasive, automa-ted ultrasonic system for the detection, localization,and coagulation of deep bleeding vessels. Although apatent related to DBAC program has been obtainedand published21, the information on successful use ofthis system is yet to be available.

CONCLUSION

The System for Temporary Control of ExternalHemorrhage in Combat-related Major ExtremityVascular Injuries described is comprehensive andinvolves a phase-by-phase increase in the amount ofcare delivered. Use of this system within the frame ofPHC algorithm after battlefield FA, during direct eva-cuation (en route care) to the site of EMC and furtherto the rear, provides for significant improvement inmortality rates in this category of casualties. By andlarge, the last decade has shown a significant break-through in the solution of THC in Combat-relatedMajor Extremity Vascular Injuries problem. Much of thisimprovement is owed to introduction of LHAs whichmay be applied from the FA phase. Regarding sophisti-cated futuristic concepts based on application of ultra-

sound and complex data processing programs, we seemto recall the words of N. Pirogov, the famous Russiansurgeon, “A new era for surgery would become, if wewill be able to stop the blood flow in a major arterywithout exploration and ligation of it”11.

SUMMARY

Already during World War II, when Russian PrehospitalCare System for Combat-related Injuries emerged, tem-porary hemorrhage control was given special attentionand was mostly delivered with tourniquets.Subsequently, introduction of new means of controlcontributed to advance in care procedures, and someforgotten prototypes designed by Russian surgeonsreceived further development, even abroad. Currently,the priority is given to limb-sparing methods of hemor-rhage control (local hemostatic agents, pressure dres-sing, clamps, etc.), whereas the ultrasound tourniquetis promising for the future. On the battlefield, the tour-niquet is the method first applied in traumatic limbamputation and proximal limb (mostly thigh) injuries.In other cases, depending on the amount of bleeding,pressure dressing or local hemostatic agents areapplied. Modernization of military medical service hasenriched the arsenal of means of prehospital hemosta-sis, with some novel limb-sparing methods introducedinto the modern Algorithm of Prehospital Care ofCombat-Related Major Extremity Vascular Injuries.

REFERENCES

11. NIKOLAYEV GF. General principles of phase-by-phasehemorrhage control treatment of combat-related casual-ties. In: Smirnov EI, Anichkov NN, Burdenko NN et al, edi-tors. Soviet medical experience during the Great PatrioticWar, 1941-1945. Vol. 3, Medgiz, Moscow, 1955, pp 175-191. [Rus]

12. PETROVSKIY BV. Short historical review of science of vas-cular gunshot injuries. In: Smirnov EI, Anichkov NN,Burdenko NN, editors. Soviet medical experience duringthe Great Patriotic War, 1941-1945. Vol. 19, Medgiz,Moscow, 1955, pp. 15–25. [Rus]

13. ZVERKOVA MP. On the issue of preoperational collateralcirculation training in traumatic aneurysms. Vestn Khir ImI I Grek. 1948, 68 (6): 23-25. [Rus]

14. ERYUKHIN IA, ZUBAREV PN, LISITSYN KM et al.Organization and content of surgical care. In: Eryukhin IA,Khrupkin VI, editors. Experience of medical provision oftroops in Afghanistan, 1979-1989. Vol. 2: Surgical care forinjuries of various localizations. Burdenko Main MilitaryClinical Hospital, Moscow, 2002, pp. 14–67. [Rus]

15. POPOV VA. Physiological principles of war surgery and emer-gency surgery. Elbi-SPb, St. Petersburg, 2003, p. 304. [Rus]

16. FOMIN NF. An anatomicophysiological evaluation of thepercutaneous ligation of the femoral vessels as a methodfor temporary hemostasis in trauma of the lower extremi-ties. Voen Med Zh, 1994, 7:32-34. [Rus]

17. TKACHENKO SS, ARTEM’EV AA, DEDUSHKIN VS. A devicefor the temporary transcutaneous ligation of the majorvessels of the extremities. Voen Med Zh, 1992, 12:58. [Rus]


VOL.87/1

Figure 9: Hemorrhage control clamp offered to controljunctional (including inguinal) hemorrhage and to check

the tourniquet status. (a) Assembled (ready-to-use) clamp.(b) Stowed clamp.

B

A


18. EASTRIDGE BJ, MABRY RL, SEGUIN P, et al. Death on thebattlefield (2001-2011): implications for the future ofcombat casualty care. J Trauma Acute Care Surg. 2012Dec; 73 (6 Suppl 5): S431-437.

19. STANNARD A, MORRISON JJ, SCOTT DJ, et al. The epide-miology of noncompressible torso hemorrhage in thewars in Iraq and Afghanistan. J Trauma Acute Care Surg.2013; 74 (3): 830-834.

10. Military field surgery of local wars and armed conflicts: aguide for surgeons, edited by EK Gumanenko and IMSamokhvalov. GEOTAR-Media, Moscow, 2011, p. 672. [Rus]

11. PIROGOFF N. Grundzüge der allgemeinen Kriegschirurgie:nach Reminiscenzen aus den Kriegen in der Krim und imKaukasus und aus der Hospitalpraxis. Verlag vonF.C.W.Vogel, Leipzig 1864: 1156 pp. [German]

12. Tactical Combat Casualty Care Guidelines.[http://www.naemt.org/Libraries/PHTLS%20TCCC/TCCC%20Guidelines%20120917.sflb]: 14 pp.

13. SHELEPOV AM, MIRONENKO AN, IGOHIN AB, et al. Conditionand development prospects of health service of army link.Vestn Ross Voen Med Acad 2012; 4 (40): 237-244. [Rus]

14. BIER A. Chirurgie der Gefasse: Aneurismen. Bruns BeitrKlin Chir 1915; 96 (4): 556-559 [German].

15. BALL CG, WYRZYKOWSKI AD, NICHOLAS JM, et al. A

decade’s experience with balloon catheter tamponade forthe emergency control of hemorrhage. J Trauma. 2011; 70(2): 330-333.

16. BLACKBOURNE LH, MABRY R, SEBESTA J, HOLCOMB JB.Joseph Lister, noncompressible arterial hemorrhage, andthe next generation of "tourniquets"? US Army Med DepJ. 2008. Jan-Mar: 56-59.

17. LYON M, SHIVER SA, GREENFIELD EM et al. Use of a novelabdominal aortic tourniquet to reduce or eliminate flowin the common femoral artery in human subjects. JTrauma Acute Care Surg 2012; 73 (2 Suppl 1): S103-105.

18. KRAGH JF JR, MURPHY C, STEINBAUGH J et al. Prehospitalemergency inguinal clamp controls hemorrhage in cada-ver model. Mil Med 2013; 178 (7): 799-805.

19. KHEIRABADI BS, TERRAZAS IB, HANSON MA, et al. In vivoassessment of the Combat Ready Clamp to control junc-tional hemorrhage in swine. J Trauma Acute Care Surg2013; 74 (5): 1260-1265.

20. NOORDIN S, McEWEN JA, KRAGH JF, et al. SurgicalTourniquets in Orthopaedics. J Bone Joint Surg 2009; 91A:2958–2967.

21. SEKINS KM, KOOK J, CALDWELL E. Systems and methodsfor performing acoustic hemostasis of deep bleedingtrauma in limbs. U.S. Patent No 2007/0066897 A1 (issuedMar. 22, 2007).

VOL.87/1



Rooter, light up your work

LED

Ergonomic and light

250 – 1200 rpm

Auto-reverse disengage mode

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FKG Dentaire SAwww.fkg.ch

By S. PLUNOI� and C. SUBUN�. Thailand

Soracha PLUNOI

Military Mobile Medical Team Unit Project,Fort Wachiraprakan Hospital, Tak Province, Thailand.*

Major Soracha PLUNOI

CURRENT POSITION:Vice President of the Quality Improvement center.

Head of Out-Patient Department.

INSTITUTE:Fort Wachiraprakan Hospital, the Royal Thai Army Medical Department.

EDUCATION:The Royal Thai Army Nursing College (2001).Master Degree of Public Administration, Ramkhamhaeng University (2012).


ARTIC

LES

ARTIC

LES

RESUME

Projet d’unité médicale militaire mobile de l’Hôpital Wachiraprakan, Province de Tak, Thailande.

Contexte : L’hôpital de fort Wachiraprakan est une formation médicale de l’armée royale Thai située dans la province de Tak, qui partage500 km de frontières avec le Myanmar. Les soldats et les habitants souffraient de malnutrition et de maladies tropicales, singulièrement dupaludisme. Les forêts, des montagnes escarpées et des moyens de transport limités sont autant d’obstacles pour joindre un service médical.Objectifs : Fournir des soins médicaux aux soldats et habitants de la région frontalière, les former à la prévention des maladiesinfectieuses et réduire la durée et le coût des consultations hospitalières.Méthodes : C’est une méthode proactive associant soins médicaux et promotion de la santé qui a été adoptée. L’équipe médicalemilitaire mobile se compose de médecins, d’infirmières et de paramédicaux collaborant avec les professionnels locaux en fournissantdes soins gratuits dans les secteurs éloignés.Résultats : Le temps de travail total a été réduit en même temps que le taux de satisfaction augmentait. L’économie réaliséereprésente environ 48 869 US dollars par an.Conclusion : Ce projet consistant en un seul passage s’est avéré coût efficace en fournissant des soins divers et en renforçant lesrelations communautaires.

VOL.87/1

KEYWORDS: Mobile medical service, Border areas, Medical expenditure, The Royal Thai Army Medical Department.MOTS-CLÉS : Equipe médicale mobile, Zones frontalières, économie médicale, Département médical de l’ArméeRoyale Thai.

BACKGROUND

Fort Wachiraprakan Hospital is a 60-bed medical facilityof the Royal Thai Army Medical Department. It is loca-ted in Tak Province which shares over 500 kilometres ofborder with Burma (fig. 1). Surveys of the hospital’sarea of responsibility revealed several key problems inproviding medical care. Mainly, these related to theoperational deployment of the Royal Thai Army forcesalong the border, which approximately 500 soldiers aredeployed along the border annually, and the local resi-dents, including ethnic minorities, having difficulties ofin accessing medical services. Forests, rugged hills andlimited transportation play an important role on beingobstacles in reaching medical services.

Tak province has the highest rate of malaria infectionin the country, as well as a high rate of respiratory ill-nesses, dermatological diseases and tooth decay. Mostof the local residents in distant and border areas have lit-tle or no formal education and basic knowledge ondisease prevention. They also have little or no access to

� MajorFort Wachiraprakan Hospital, Mai Ngam, Mueng, Tak, Thailand 63000

Correspondence :Major Soracha PLUNOIFort Wachiraprakan Hospital, Mai Ngam, Mueng, Tak, Thailand 63000Tel.: +66-55-514375 ext. 27Email: [email protected].

* Presented at the 2nd ICMM Pan-Asia Pacific Congress on Military Medicine,Bangkok, Thailand, 27-30 November 2012.

Mobile Medical Team Unit Project_PLUNOI_Mise en page 1 13/03/14 18:17 Page1

family planning or other public health services such asbreast and cervical cancer screening. Both the militarystaff and the local residents lack adequate communica-tion equipments. There are not enough medical facilitiesand most are located too far to be easily reached by thepopulation. Moreover, the civilians are unaware thatthey can also receive medical treatments in a militaryhospital. As a result, a large amount of money was spenton transportation costs to travel to the provincial hospi-tal. The local population spent approximately over 1.5million Baht a year in travel expense to reach medicalfacilities in the province.

In light of these problems, Fort Wachiraprakan Hospital,Tak Military District and the Naresuan Field Force imple-mented mobile medical team operations since 2007 toprovide medical services to both military personneldeployed on operations and the local residents inremote areas.

Previously, military personnel and civilians had to travelup to 7 or 8 hours to get to a hospital in order to beexamined by a doctor for 10-15 minutes.

Not only being time consuming, this also increased dis-comfort for the patients and risk of spreading diseases.

To deal with these problems, a more pro-active approachwas adopted, officially called “Paet Tahan RaksPrachachon” (“Military Medics Caring for the People”).This project aimed to bring basic medical services andhealth promotion to those in need in distant areas toreduce the need for difficult and costly visits to hospital.

This comprehensive effort involved a wide range ofactivities from medical treatment, health educationand basic first-aid training to annual blood tests formilitary personnel.

OBJECTIVES

This project emphasized on a “patient-centered Service”which aimed to;1. Promote good health among military personnel andthe general population in remote border areas.2. Reduce the difficulty and expense of visiting a hospital.3. Provide knowledge in basic life support and cardio-pulmonary resuscitation (CPR).4. Reduce medical expenditure by using disease preventionmeasures.5. Reduce mortality rate from malaria.6. Improve trust and relation between the military andlocal residents, especially ethnic minorities, with medical-led psychological operations.


VOL.87/1

Fig. 1: Location of Fort Wachiraprakran.Tak Province is in the northwest frontier adjacent to Burma,

painted by the red color in the Map.

Mobile medical team providing medical servicesto both military personnel deployed on operations

and the local residents.

Medical military personnel caring for the people.

•


METHODS

The military mobile medical team was multi-disciplinary,consisted of physicians, nurses, pharmacists, medical tech-nicians, social workers, nutritionists and other supportingstaff. Team operations were supervised by the hospitaldirector to ensure the necessary provision of funds, equip-ments, medication and medical supplies. Besides, the teamalso received full material and moral supports from all sec-tors, including Tak Military District and the Naresuan FieldForce. This project was conducted every 3 months, provi-ded medical treatment, health education, basic first aidtraining and annual blood tests for military personnel, butit also depended on weather and political situations. Theprovided services reduced process from traditional practiceusing “Lean concept”, which analyzed the whole processto reduce unnecessary steps to achieve the objectives.

OUTCOMES

Since 2007, the number of patients in each visit variedfrom 150 to 500. Each place was different but had thesame outcome.

1. Time consumption

The mobile medical team significantly reduced theamount of time on travelling to and from the hospitalin order to receive medical treatment. The average tra-velling time by motor vehicles from border areas toFort Wachiraprakan Hospital was 4 hours, so togetherwith the return trip it was up to 8 hours spent on justtravelling alone.

With traditional process at the hospital, the patienthad to go through a 4-step/ 8-service-station processtaking up other 95 minutes from the start to finish.

In summary, patients seeking treatment at the hospitalneeded up to 9 hours and 35 minutes for each visit.

On the other hand, with the mobile medical team usinglean method, reduced the process to 3 steps/ 2 servicestations which only took 10 minutes to complete, sothere were more time spared for health education andhealth promotion.

2. Malaria mortality (See figure 5)

3. Basic life support and cardiopulmonary resus-citation skills (See Figure 6)

The session of basic life support education, a 30-minutedemonstration followed by hands-on practice, was pro-vided aiming mainly on military personnel to refreshtheir skills but the local residents were also welcome tojoin. A simple skill assessment, comprised of 10-stepcheck-list, was performed by the instructors, with thetotal score of 80% as being satisfactory.

4. Service satisfaction (See Figure 7)

5. Cost

As a result of the medical mobile team’s work, the totalexpenditure was cut by 48,869 US per year.

CONCLUSION

This service-oriented project achieved maximum bene-fit for patients and provides;

• One-Stop Service.• Pro-Active Effort.• Cost Effectiveness.• Diverse Treatments.• Strengthening trust and community relations.


VOL.87/1

TRADITIONAL PROCESS NEW PROCESS

• History taking• Vital signs measurement• Weight and height measurement

• Blood chemistry investigation

• Physical examination• Medical prescription

• Drug education by the pharmacist

• History taking• Vital signs measurement• Weight and height measurement• Blood chemistry investigation



Figure 2: Comparaison between traditional and new process.

• History taking• Vital signs measurement• Weight and height measurement

• Blood chemistry investigation



Figure 3: Time consumption on the traditional process.

10 minutes

60 minutes

10-15 minutes

12 minutes

Military mobile medical team. TRADITIONAL PROCESS


piperaquine tetraphosphate / dihydroartemisinin

File

d at

AIFA

on

9/09

/201

3

In 2010, Fort Wachiraprakan Hospital received TheQuality Public Service Award from the Public ServiceDevelopment Committee (PSDC).

SUMMARY

Background: Fort Wachiraprakan Hospital is a medical faci-lity of the Royal Thai Army Medical Department in Tak pro-vince, which shares over 500 kilometres of border withBurma. Soldiers and local residents suffered from problemssuch as malnutrition and tropical infections, especiallymalaria. Forests, rugged hills and limited transportation aremain obstacles in reaching medical services.Objectives: To provide medical care to soldiers and people inborder areas, educate self-care protection against infec-tious diseases and reduce time and cost of hospital visits.Methods: A pro-active approach providing basic medical

services and health promotion was adopted. The“Military Mobile Medical Team” consists of physicians,nurses and paramedics, collaborated with local staff todeliver services into distant areas free of charge.Results: Total service time was reduced with increasingtrend in satisfaction rate. Total expenditure was cut by48,869 US per year.Conclusion: This project provided a one-stop service,cost effectiveness, diverse treatments and strengtheningcommunity relations.


VOL.87/1

2007 2008 2009 2010

100

90

80

70

60

50

40

30

20

10

0

Skill Level of Military Personnel and Civilians

%

SKILL LEVEL OF MILITARY PERSONNEL AND CIVILIANS

Figure 6: The basic life support and cardiopulmonaryresuscitation skill level of military personnel and civilians

attending health education session, from 2007-2010.

2007 2008 2009 2010

100

90

80

70

60

50

40

30

20

10

0

Customer Satisfaction

CUSTOMER SATISFACTION

Figure 7: The customer satisfaction rate on the militarymobile medical team from 2007-2010.

INDICATORS OLD-PROCESS PATIENTS

EXPENDITURE (US/YEAR)NEW-PROCESS PATIENTS

EXPENDITURE (US/YEAR)HOSPITAL EXPENDITURE

(US/YEAR)

1. Loss of income from travelling toseek medical treatment

33313 5806 -

2. Transportation cost 25375 - 1045

3. Value of medical prescription - - 2967

TOTAL 58688 5806 4012

Table 1: Expenditure comparison between traditional process and the military mobile medical team’s new process,for both patients and the hospital.

Mortality cases

(-) Number of patients treated15 (750) cases

(985 cases)0

(165 cases)0

(56 cases)0

12 (700 cases)

5 (1,250 cases)

Year2007 2008

20

10

0

2009 2010 2011 2012

CaseMORTALITY RATE OF MALARIA

Figure 5: The mortality rate of malaria from 2007 to 2012in Fort Wachiraprakan Hospital.

NEW PROCESS

• History taking• Vital signs measurement• Weight and height measurement• Blood chemistry investigation



Figure 4: Time consumption on the new process.

4 minutes

5 minutes

1 minutes

5460

80 82

7882

95 96,25


By J. BANCKEN. Belgium

Johan BANCKEN

The Modus Operandi of the Module Battle StressRecovery Unit (Mod BSRU) Deployed to UNIFILfrom October 2006 until March 2009.

Johan BANCKEN (1963) joined the Ministry of Defence in 1984 and was stationedin Xanten and Werl as a member of the Belgian Forces in Germany.

In 1993 he was assigned as a secretary of the Centre for Crisis Psychology (CCP) inthe Queen Astrid Military Hospital (QAMH) in Brussels.

He graduated in 2001 as an Assistant in psychology and worked as a coordinator of critical incidents in theCCP. Since 1996 he is also a lecturer at the Competention Centre of the Medical Component (CC MED) inthe field of stress management and trauma.

In february 2010 he was promoted to OR-9 and as such transferred to his current position as an Assistanteducation manager of the Department Education – Quality Cell of the CC MED.

Long standing Military Missions in a Belgian multidisciplinary Psychosocial Team:- 1994: Operation Silver Back (United Nations Armed Military Operation in Rwanda);- 2006: Operation BELUFIL 1 (Belgian Luxemburg Forces in Lebanon);- 2007: Operation BELUFIL 4;- 2008-2009: Operation BELUFIL 7.


ARTIC

LES

ARTIC

LES

RESUME

Fonctionnement de l’unité de traitement du traumatisme psychique de guerre (Module battle stressrecovery unit, Mod BSRU) au sein de la FINUL d’octobre 2006 à mars 2009.

Les missions à l’étranger comportent des risques pour le personnel de la Défense. Les accidents provoquant des blessures, voiredes décès ne sont pas à négliger. Par ailleurs, il arrive que les militaires soient confrontés à une extrême violence durant ces missions.Des difficultés psychologiques et sociales durables peuvent être déclenchées par une confrontation inattendue avec la mort ou parune menace contre l’intégrité physique. Ces situations de crise mettent la personne dans un état d’impuissance et d’angoisseimportant. Le Centre de Psychologie de Crise de l’Hôpital Militaire Reine Astrid offre aux militaires concernés un soutien psychologiquenécessaire dans ces cas. L’objectif fixé est d’aider la personne à retrouver un équilibre psychologique et social satisfaisant. Le Module‘Battle Stress Recovery Unit (BSRU)’, émanation du Centre de Psychologie de Crise et peut être appelé à participer à certainesopérations à l’étranger. Le Module BSRU est prévu pour accueillir et soutenir les militaires victimes ou témoins d’un incident critiquedurant une mission, mais également les civils Belges devant être évacués de la zone de conflit.

VOL.87/1

KEYWORDS: Battle Stress Recovery Unit, Fieldhospital, Psychological support, UNIFIL, Lebanon.MOTS-CLÉS : Unité Battle Stress Recovery, Hôpital de campagne, Soutien psychologique, FINUL, Liban.

AIM

The aim of this article is to explain the functioning of theBelgian military Module Battle Stress Recovery Unit (ModBSRU), a psychological support module, during deploymentin the UNIFIL-BELUFIL mission. The quantitative material14

was collected during the presence of the Mod BSRU as a partof the Belgian Medical Treatment Facility Role 2 Enhancedin Tibnin (Lebanon). The team Mod BSRU collected data(concerning the core businesses and the tasks) from the fieldjournal, case-studies, incidents and mission reports.

This material and the Lessons Learned cover the periodOctober 2006 – March 2009. The 7 steps Psychological

Correspondence :Johan BANCKENOR-9Competention Centre Medical ComponentDepartment Education – Quality CellBruynstraat 1BE-1120 BRUSSELSBELGIUMTel.: + [email protected]

Mod BSRU_BANCKEN_Mise en page 1 13/03/14 18:26 Page1

By J. BANCKEN. Belgium

Johan BANCKEN

The Modus Operandi of the Module Battle StressRecovery Unit (Mod BSRU) Deployed to UNIFILfrom October 2006 until March 2009.

Johan BANCKEN (1963) joined the Ministry of Defence in 1984 and was stationedin Xanten and Werl as a member of the Belgian Forces in Germany.

In 1993 he was assigned as a secretary of the Centre for Crisis Psychology (CCP) inthe Queen Astrid Military Hospital (QAMH) in Brussels.

He graduated in 2001 as an Assistant in psychology and worked as a coordinator of critical incidents in theCCP. Since 1996 he is also a lecturer at the Competention Centre of the Medical Component (CC MED) inthe field of stress management and trauma.

In february 2010 he was promoted to OR-9 and as such transferred to his current position as an Assistanteducation manager of the Department Education – Quality Cell of the CC MED.

Long standing Military Missions in a Belgian multidisciplinary Psychosocial Team:- 1994: Operation Silver Back (United Nations Armed Military Operation in Rwanda);- 2006: Operation BELUFIL 1 (Belgian Luxemburg Forces in Lebanon);- 2007: Operation BELUFIL 4;- 2008-2009: Operation BELUFIL 7.


ARTIC

LES

ARTIC

LES

RESUME

Fonctionnement de l’unité de traitement du traumatisme psychique de guerre (Module battle stressrecovery unit, Mod BSRU) au sein de la FINUL d’octobre 2006 à mars 2009.

Les missions à l’étranger comportent des risques pour le personnel de la Défense. Les accidents provoquant des blessures, voiredes décès ne sont pas à négliger. Par ailleurs, il arrive que les militaires soient confrontés à une extrême violence durant ces missions.Des difficultés psychologiques et sociales durables peuvent être déclenchées par une confrontation inattendue avec la mort ou parune menace contre l’intégrité physique. Ces situations de crise mettent la personne dans un état d’impuissance et d’angoisseimportant. Le Centre de Psychologie de Crise de l’Hôpital Militaire Reine Astrid offre aux militaires concernés un soutien psychologiquenécessaire dans ces cas. L’objectif fixé est d’aider la personne à retrouver un équilibre psychologique et social satisfaisant. Le Module‘Battle Stress Recovery Unit (BSRU)’, émanation du Centre de Psychologie de Crise et peut être appelé à participer à certainesopérations à l’étranger. Le Module BSRU est prévu pour accueillir et soutenir les militaires victimes ou témoins d’un incident critiquedurant une mission, mais également les civils Belges devant être évacués de la zone de conflit.

VOL.87/1

KEYWORDS: Battle Stress Recovery Unit, Fieldhospital, Psychological support, UNIFIL, Lebanon.MOTS-CLÉS : Unité Battle Stress Recovery, Hôpital de campagne, Soutien psychologique, FINUL, Liban.

AIM

The aim of this article is to explain the functioning of theBelgian military Module Battle Stress Recovery Unit (ModBSRU), a psychological support module, during deploymentin the UNIFIL-BELUFIL mission. The quantitative material14

was collected during the presence of the Mod BSRU as a partof the Belgian Medical Treatment Facility Role 2 Enhancedin Tibnin (Lebanon). The team Mod BSRU collected data(concerning the core businesses and the tasks) from the fieldjournal, case-studies, incidents and mission reports.

This material and the Lessons Learned cover the periodOctober 2006 – March 2009. The 7 steps Psychological

Correspondence :Johan BANCKENOR-9Competention Centre Medical ComponentDepartment Education – Quality CellBruynstraat 1BE-1120 BRUSSELSBELGIUMTel.: + [email protected]


Support Plan18 (PSP) that gives guidelines for providingpsychological support after a critical incident areexplained.

INTRODUCTION

1. In general

In 1978, the United Nations Interim Forces in Lebanon(UNIFIL) were founded by the Security Council of theUnited Nations. This in order to (1) confirm Israel’swithdrawal from Lebanon, to (2) restore internationalpeace and security and to (3) assist the LebaneseGovernment in restoring its effective authority in thearea6, 7, 8.

Following the July/August 2006 conflict, between Israeland Hezbollah, in southern Lebanon, the Councilincreased its troop strengths from 2000 troops inAugust 2006 to 12000 at the end of January 2007,consisting of contingents of 28 nations. The maximumnumber of UNIFIL peacekeepers has been noted at15000. With the United Nations mandate ‘resolution1701’of August 2006, UNIFIL received the mission toassist the Lebanese Armed Forces in the establishment,in the southern Lebanon, of an area free of any armedpersonnel other than those of the Government ofLebanon and of UNIFIL.

On the 25th August 2006, the Belgian government1, 2

proposed the UN its own participation. This participa-tion had to give an answer to the needs of the UN, andmoreover, was to be a useful part in the reconstructionof Lebanon. The Belgian government proposed a parti-cipation in the demining field, the reconstruction andthe medical services. The mission of ‘the BelgianLuxemburg Forces in Lebanon (BELUFIL)’ was born.

2. The Medical Treatment Facility (MTF)

The standards of medical care in crisis have to be asclose as possible to prevailing peacetime medical stan-dards. This means Primary Surgery (PS) within one hour,or when not feasible Advanced Trauma Life Support(ATLS) within one hour, Damage Control Surgery (DCS)within two hours, Primary surgery (PS) within fourhours (Golden hour-principle).

The medical part of the Belgian participation consistsof a primary health care facility Role 1 (AdvancedTrauma Life Support (ATLS) and Evacuation) and on theother hand a Role 2 medical support entity (FieldHospital - Role 2 Enhanced). It is a Modular built uphospital providing an intermediate capability for thereception and triage of casualties, as well as being ableto perform resuscitation and treatment of shock to ahigher technical level than Role 1. It will routinelyinclude Damage Control Surgery and may include alimited holding facility for the short term holding ofcasualties until they can be returned to duty or evacua-ted. The Role 2 Enhanced had additional capabilitiessuch as preventive medicine, environmental healthcapability, dental care, operational stress management,psychiatry or psychology13.

The Mod BSRU5, 9 is such an additional module. TheMod BSRU is a specialised psychological module of theCentre for Crisispsychology (CCP) from de Queen AstridMilitary Hospital (QAMH) - a part of the MedicalComponent (MC) of the Belgian Ministry of Defence(MoD) - located in Brussels (Belgium).

According to UN instructions, this Role 2 Enhanced hos-pital is to support a UN population in the South ofLebanon of approximately 5000 personnel (total popu-lation at risk). This medical facility had the capacity toperform3-4 surgical operations a day with anesthesia,emergency resuscitation procedures and to stabilise thehealth state of the patient, thus enabling evacuation tothe next level of medical care.

MODULE BATTLE STRESS RECOVERY UNIT17

(MOD BSRU)

1. Mission – Core Business

The ‘missions' are the core business of the Mod BSRU.The Mod invested in professional and specific trainingsfor the Mod BSRU-personnel, the provision of the nee-ded materials and of the appropriate infrastructure.

1.1.Psychological support after a critical incidentExamples of potential critical incidents are: armedconflict, terrorism, air accidents, heavy road accidents,technological accidents, industrial accidents, naturaland man-made disasters,… During missions abroad, themilitary personnel may also suffer extreme violence.


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Field Hospital Role 2 Enhanced.

Queen Astrid Military Hospital - Brussels.

© Photo Archives Audiovisuelles de la Défense DG-COM


Such incidents are unexpected, provoke feelings of hel-plessness and impair the feelings of safety and control.They can incite long-term psychological and socialimpairment. Victims may need support in psychologi-cally working through the incident and the emotionalupheaval this caused.

In the described period 16 critical incidents were regis-tered (demining incidents, general work accidents,road accidents with deaths, a shooting incident withlethal consequences, burn injuries of a local child,smoke bomb incident, amputation,…).

1.2.Psychological evaluation in case of repatriationbecause of psychological or social reasonsSome UNIFIL troops may be confronted with difficulties ofa psychological/psychiatric, social or family nature. Thesedifficulties may reduce their operational functioning. Arepatriation can in that case be an appropriate measure.Advice is provided in order to decide whether repatriationis appropriate and whether there should be opted for atemporary or permanent repatriation. The Mod BSRU hasa surplus value in the domain of the assessment of theperson and his/her situation. Support and advice in thismatter is given to the Senior Medical Officer.

A BELUFIL-specific procedure for repatriation, withdecision tree, was written during the missions.

For 62 repatriations the advice of the Mod BSRU wasrequested.The aftermath of a critical incident, a funeral, hospitali-sation of a family-member, a sick child, death of a mea-ningful person (in operation or at home), personal pro-blems, rotation policies, alcoholabuse, relationship diffi-culties, medical evacuation, psychiatric decompensa-tions, general anxiety disorder,… were possible reasonsto be repatriated.

1.3.Psychological support in case of psychological oremotional difficultiesPsychological difficulties may occur within some indivi-duals during the course of the deployment (depressivesymptoms, anxiety, symptoms of personality disorder,…).The operationality of these individuals can sometimesbe maintained during the period of deployment whenpsychological counseling is provided.

During the described period, a total of 592 individualcounseling sessions was registered. The content ofthese sessions usually was about work-related pro-blems, the follow-up of crisis interventions and difficul-ties linked to the homefront.

1.4.LiaisonThe Mod BSRU has the role of external and internal liaison:The Mod BSRU cooperated in Lebanon with its otherpsychosocial partners in the Mod. The representative ofthe Mod BSRU is a member, and supervisor, of thePsychosocial Team10, 11, 12. The Psychosocial Team in theBELUFIL mission consisted of representative (s) of (1)the Service Mental Readiness Advisors in Operation (aLand Component Psychologist), (2) the Social Servicesand (3) the Service of Religious and Moral Support (aChaplain and/or a Moral Advisor). This PsychosocialTeam is at the service of the BELUFIL commander. ThePsychosocial Team of BELUFIL cooperates with thePsychosocial Services in Belgium. Cooperation with col-leagues in Belgium is important because psychologicalsupport may also be needed for the families of theinvolved servicemen or their co-workers at the unit inBelgium.

There is communication with the physicians and otherpersonnel of the Medical Component (MC) stationed atthe compound. The Mod BSRU may provide them withadvice on psychiatric co-morbidity, help them withannouncing bad news, reacting to psychologicaldecompensation, ….

As military personnel, the members of the Mod BSRUalso took part in daily life and activities at the com-pound. This in order to lower the threshold for askingsupport.

2. Tasks17

‘Tasks’are activities carried out on a non- permanentbase and only in function of the exceptional situa-tion/incident or available resources.

2.1.Mediation in case of interpersonal or professionalconflictsInterpersonal conflicts may arise during deployment.These may put the group cohesion and/or the quality ofthe execution of the assignment at risk. Mediation candiminish this risk. The BSRU – team actively takes part


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Module Entry.

Team CCP - 2010 - Cfr Acknowledgements.


in the functioning of the Field Hospital and the MedicalInstallation. This pro-active but non-intrusive approachwill enable the Mod BSRU to detect possible interper-sonal or professional conflicts at an early stage. Earlydetection and individual or group counselling may preventescalation.

In the described period, 55 mediations were registered.This concerned intra- and interpersonal difficulties bet-ween military personnel from different Modules, bet-ween military personnel from different components,with locals, within hierarchical structures, within man-woman relationships, …

2.2.Active outreach, psycho-education and preventivemeasuresActive outreach is the preferred strategy of the ModBSRU when it comes to (stress) prevention and earlydetection of possible emotional difficulties. The ModBSRU will engage in actions which can contribute tothe prevention of harmfull psychological processes.Workshops and presentations will be organised toenhance the coping-strategies of the participants in thedomain of ‘operational stress management’, ‘helpingcolleagues after incidents’, ‘coping with intense emo-tions’. Other initiatives were outreach leaflets, writingand spreading articles.

302 Psycho-education initiatives were registered in thedescribed period: Presentation ‘Functioning of the ModBSRU’, ‘Stress Management in operation’, ‘Managingcritical incidents’, ‘Self care’, ‘Managing your emo-tions’, ‘Going home’, ‘How to handle your childrenduring deployment, ‘Gossip for dummies’, …

2.3.Humanitarian psychological interventionsThe Mod BSRU may provide humanitarian help to thelocal population ‘within means and capabilities’. Thelocal population (war victims before 2006 included) isalso a rightful claimant for psychological support aftera critical incident and for individual counseling.

There are no exact data about the amount of indivi-dual counseling sessions dedicated to locals. In the

observed period a number of 16 critical incidents wasrecorded, 4 of these incidents concerned locals amongthe victims.

3. Personnel

The following military professions can be selected for asingle representation or a team3, 4: masters and bache-lors in psychology (clinical psychologists and assistantsin applied psychology), psychiatric nurses and trainedmilitary ambulance personnel.

The personnel of the Mod BSRU is required to be ableto deliver psychological first aid to individuals andgroups and should be able to provide advice on issuessuch as how to help victims of critical incidents.

During these three years of effort, almost everyemployee of the CCP was involved in the BELUFIL ope-ration abroad and different formats were tried out: (1)Continuous presence of a team of 2 military professio-nals, (2) Continuous presence of 1 representative, (3)Rotation of personnel after 1 month, (4) Rotation ofpersonnel after 2 months, (5) Rotations with andwithout overlap and a (6) Contact team present for onlya short period of time during long-term deployment.

4. Location of the Mod BSRU

Counselling sessions took place in a calm and privateatmosphere located in the centre of the compound(‘Camp Scorpion’in Tibnin).

PSYCHOLOGICAL SUPPORTAFTER A CRITICAL INCIDENT

1. Different levels of psychological support aftera critical incident

1.1.Preventive actionsThese are actions that contribute to the prevention ofa possible difficult psychological adaption proces. Anobstruction in the adaptation process may lead to dys-functions within an individual and within the group.

Examples of preventive actions:Expliciting the role of the commando in function of‘Critical incident stress management’, Explaining the 7steps Psychological Support Plan (7 steps PSP) as it willbe applied after an incident, Training key personnel inhow to intervene after an event, Organising workshopsto facilitate the coping-mechanisms (‘How to handleintense emotions’, ‘Active listening’, ‘How to help col-leagues after a critical incident’)

1.2.Support after a critical incidentThe aim of this kind of support is also to enhance thenatural adaptation process after a critical incident.

In case of a critical incident, the provided psychologicalsupport (for groups or a team) is based on a 7 steps PSP.The Psychosocial Team coordinates, organises andguides these different steps for every critical incident inwhich military personnel of BELUFIL is involved.


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advancingsepsis

managementEarly identification of sepsis is crucial to improving patient outcomes. Yet sepsis can be difficult

to differentiate from nonbacterial infections. Procalcitonin (PCT) is a biomarker that exhibits a

rapid, clinically significant response to severe bacterial infection. In patients with sepsis, PCT

levels increase in correlation to the severity of the infection. Adding the PCT biomarker assay

can help improve the accuracy of risk assessment in sepsis1 and guide therapeutic decisions.2,3

Procalcitonin (PCT)

advancingsepsis

managementEarly identification of sepsis is crucial to improving patient outcomes. Yet sepsis can be difficult

to differentiate from nonbacterial infections. Procalcitonin (PCT) is a biomarker that exhibits a

rapid, clinically significant response to severe bacterial infection. In patients with sepsis, PCT

levels increase in correlation to the severity of the infection. Adding the PCT biomarker assay

can help improve the accuracy of risk assessment in sepsis1 and guide therapeutic decisions.2,3

Procalcitonin (PCT)

1.3.Ongoing long-term supportA critical incident that takes place during a mission willbe followed-up (1) during and (2) after the period ofdeployment. There will also be a psychosocial hometeam that provides support for family members.

So, the Psychosocial Team in operation engages itself toactivate the simultaneously working psychosocial ser-vices in Belgium and needs to assure ongoing psycholo-gical support over time, even in Belgium, when needed;

2. The 7 steps Psychological Support Plan18 (PSP)after a Critical Incident

2.1.HistorySince the disaster with the ferryboat ‘Herald of FreeEnterprise’(1987) there was a lot of thinking in Belgiumabout the possible set-up of psychosocial support forvictims and caregivers after minor or major critical inci-dents. During the nineties a National PsychosocialDisaster plan (A project from the Ministry of SocialAffairs, Ministry of Health and Environment and theMinistry of Defence18) was written down.

The National Psychosocial Disaster plan had 2 axes ofinterest: (1) the victim and his/her environment and (2)the policy and its anticipation-network. The result is astructural plan to be able to prevent residual lesions invictims of critical incidents and their families.

2.2.AimThis 7 steps PSP aims the recovery of the psychosocialbalance from the victim and its immediate environment(in our case usually family and/or military community). Itis applied to prevent residual lesions. Psychosocial sup-port can reduce the number of victims that have long-term psychosocial consequences after a critical incident.

2.3.The 7 steps PSPThe supportive actions that need to be taken by theMod BSRU when a critical incident happens are writtendown in these 7 steps. The aim is to answer to theneeds of the victims and their environment.

The 7 steps are: 1. Description of the event:

The event is defined: What? How? Where? When?2. Identification of the target groups:

Who/which groups is/are affected in which way by thatparticular incident?

3. Estimation of the possible psychosocial conse-quences:Immediate-term, short-term, medium and long-term.

4. Identification of the needs:By means of observation, listening and gathering infor-mation, an analysis is made of the needs of the diffe-rent target groups. To become good results in this step,a proactive approach of the Psychosocial Team isrecommended.

5. Working out an intervention strategy:What actions/interventions (in function of needs andpriorities) for which target groups? How? With whichpartners? Where? When?

6. Evaluation of the availability of caregivers:Is the capacity of caregivers sufficient enough to meetthe needs? It is possible that the psychosocial team willnot be able to answer all the needs. This will be reportedto the Commander.

7. Evaluation of the activities and reevaluation ofneeds:Have the activities proven to be effective in preventinglong-term impairment? Were they effective in theunderstanding and the management of the situationof distress?

During these 7 steps the Pychosocial Team will take theinitiative to inform the psychosocial actors of thehomefront. The Psychosocial Team advises the hierar-chy to take the necessary actions in order to inform thefamilies of the victims. It is very important that the cor-rect information about the facts and circumstances iscommunicated to the right people. In case of death,the psychosocial team takes action to communicate thebad news to the families. If the victims are woundedand their medical condition allows it, then it is prefer-red that they themselves inform their own family.Assistance can be provided by a member of thePsychosocial Team or by someone of the command. Ifthe injuries make this impossible, then a member of thePsychosocial Team announces the bad news.

The necessary communication canals are foreseen totransmit all related information to the in-theatherBELUFIL personnel.

They will assist the relatives of the victims and will pro-vide, if necessary, long-term psychosocial support, evenin Belgium after deployment.

LESSONS LEARNED17

The Lessons Learned are joined, taking the 3 stages ofa military mission into account: (1) before, (2) duringand (3) after the mission).

1. Stage 1: Before the mission

The Mod BSRU should take part in all preparatory mili-tary exercises. This can be very useful to get intocontact with the participants of the mission and to startbuilding up a relationship. This should lower the thres-hold to ask for help and support during the mission. All members of the Psychosocial Team (home & awayteam) should meet each other pre-deployment, so thatthe network can be efficiently used during the missionand that they can work together in the most smoothfulway possible.

Because of the uncertain character of the politicalsituation during a mission and because of the unexpec-ted character of critical incidents it is important thatthe Mod BSRU and its personnel should always beready and prepared to leave on a mission.

2. Stage 2: During the mission

A permanent presence was better than a temporary


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contactteam. The temporary contactteams faced inte-gration problems, which raised the threshold for askingsupport instead of lowering it.

A rotation of personnel every two months was the bestformulae for the Mod BSRU in the BELUFIL-operations.In this format a certain continuity and thus a lowerthreshold for asking psychological support was guaran-teed. This formula also had the least consequences forthe home team. An overlap in rotation was necessaryto guarantee a good follow-up of the activities.

Psycho-education, and other activities related to this,facilitated the accessibility to the Mod BSRU.Organising trainings for key personnel also had thissame positive effect.

The way the Mod BSRU works is complementary to andin cooperation with the other members of thePsychosocial Team. It is necessary to explicit the man-date of the Mod BSRU and that of its partners to all thedeployed personnel.

Location and accessibility proved to be important.Counselling sessions should take place in a privateatmosphere. The best place for the Mod BSRU to belocated was between the hospital and the privateaccommodations.

Good cooperation with the physicians of Role 1 and 2 isimportant for good references and lowers the threshold.

The Mod BSRU had an international character. Othernationalities made also use of these services. Taking intoaccount this international character, cooperation withtranslators is sometimes necessary to achieve good results.

The representative of the Mod BSRU is counsellor andmilitary at the same time. Being a military and takingpart in the daily activities lowers the threshold.

3. Stage 3: After the mission

Information and reports of the work done during theoperation must be passed through to the home teamso a correct follow-up can be organised.

FUTURE

A good screening of participants before departureshould remain a point of attention. In this way psy-chiatric and/or psychological problems surfacing duringthe mission can be reduced to a minimum. The Centrefor Medical Expertise (CME)-New in the QAMH is anexcellent answer for such a screening for all militarypersonnel before going on a mission.

A Specific Procedure (SPS) after critical incidents was writ-ten down. This allows that all information of critical inci-dents is passed on to the Operational Centre of Defence(COps). COps activates all relevant psychosocial actors,taking the needs of the specific situation into account.

All Belgian military psychologists followed a course

‘Crisis psychology’. This course is given by the personnelat the CCP. Taking part in the course ‘Disaster manage-ment and Disaster medicine’at the University of Leuvenand Brussels is a good preparation for the CCP-person-nel in the reception of ‘after Mass Casualties’.Competencies and expertise in the field of critical inci-dents and trauma needs to be maintained by permanentin-service training (f.e. participating at the ConferenceEuropean Society for Traumatic Stress Studies – ESTSS, acounselor training, training in mediation, training inannouncing bad news,…).

Training the personnel of Mod BSRU in the English lan-guage is wishful because of the international characterof the Mod BSRU.

Taking part in military exercises is also necessary for thepersonnel Mod BSRU to be able to keep up with theneeded military skills.

The cooperation between the existing national andregional platforms and the other psychosocial partnersin the Mod should be maximised.

DISCUSSION

It is important to mention again and emphasise thatthe Mod BSRU-personnel works with a thorough know-ledge of ‘psychotraumatology – victimology – crisis psy-chology’. The 7 steps PSP was well researched beforeimplementing it. Also the quantitative material thatwas collected was never registered in a standard man-ner. In future, there could be worked with evaluationforms to be filled in after every session or after everyinitiative. This may shed more light on strengths andweaknesses and the exact ways in which the Mod BSRUcontributes to the psychological well-being of militarypersonnel during and after deployment. In future mis-sions it would also be useful if there is a standardisa-tion in the way the activities of the Mod BSRU are regis-tered. The critical incidents that happened during themissions were all supported by using the 7 steps PSPdescribed above. In this we need to trust on the posi-tive feedback that the personnel of the Mod BSRUregularly received from their ‘clients’ and co-workers. Itcould also be useful to research which elements of thesteps are the most useful.

The personnel of the Mod BSRU must be able to supportthe military personnel during deployment. The personnelof Mod BSRU of course is also deployed and is not freefrom the potential troubles and problems military per-sonnel in deployment comes across with. It is very impor-tant that the personnel Mod BSRU also are supported.The other members of the Psychosocial Team may have avery important role in this. A strong and good functio-ning psychosocial network is thus not only important forthe ‘clients’ but also for the caregivers themselves.

CONCLUSION

The permanent presence of a representative of theModule BSRU, for a period of 2 months for the describedBELUFIL-missions (BELUFIL 1 to 8/1) during the activities

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of the Medical Treatment Facility Role 2, was a surplusvalue and an optimal format for the psychosocial care ofthe military personnel and their hierarchy. A good‘hand-over and take-over’ of information (about severalachievements and files) at the rotations was very importantfor the continuity of the psychosocial care.

Based on the feedback given by victims, the 7 steps PSPproved to be an effective model.

Acknowledgments

1. First I like to dedicate this article to Luc Quintyn16 (†).He was the founder and the formal Chief of the CCP(1990 until 1999) who passed away on the 22 october2011. As a clinical psychologist - philosopher his com-mitment led to a structural and scientifically foundedapproach to the prevention of psychotrauma and thecare for victims of traumatic experiences within theMinistry of Defence as well as in several civil organiza-tions (national and international).

2. Secondly I like to thank the personnel of the CCP, notonly for supporting me with data for this article, butalso for the intens collaboration during the past eigh-teen years (1993 – 2011). Thanks for the opportunity tobe at your service!

ABSTRACT

Military missions abroad intrinsically entail certain risksfor the deployed personnel. Servicemen are sometimesinvolved in incidents that can cause severe physicalinjury, sometimes even with fatal consequences. Duringmissions abroad the military personnel can sometimesundergo situations with extreme violence. Theseordeals mostly provoke feelings of helplessness and areoften unexpected and dreadful exposures to death ormutilation. These so-called “critical incidents” canincite long-term psychological and social impairment. The Centre for Crisis Psychology (CCP) of the QueenAstrid Military Hospital (QAMH) offers the necessarypsychological support for the distressed servicemen inorder to facilitate their mental recovery-proces. The‘Battle Stress Recovery Unit (BSRU)’ is the module ofthe CCP, deployable during military missions abroad

(embedded in a Medical Treatment Facility (MTF) Role2 or as a stand-alone module during Non-combattantEvacuation Operations (NEO).

The missions (core business) of the module BSRU are (1)psychological support after critical incidents, (2) psy-chological evaluation in case of the repatriation of aservice member for psychological/psychiatric reasons,(3) psychological support in case of psychological or emo-tional difficulties and (4) ensuring the liaison functionbetween the different entities of the MTF.

The tasks (activities on a not permanent base and infunction of the available resources) of the moduleBSRU are (1) mediation in case of interpersonal or pro-fessional conflicts, (2) psycho-education and (3) huma-nitarian psychological interventions (‘within means andcapabilities’).

The composition of the BSRU depends on the deploy-ment scenario (NEO, Peace Support Operations (PSO) orPeace Enforcement Operations (PEO). This personnelcomposition can entail a (clinical) psychologist, a psy-chiatric nurse, an assistant in psychology and ambulance-servicemen.

The personnel of the module BSRU can deliver psycho-logical first aid to individuals or groups and can giveadvice in coping with severe incidents. The moduleBSRU will inform actively, cooperate and coordinatethe follow-up of these incidents with other members ofthe Psychosocial Team present in the battle group andwill simultaneously inform the psychosocial services onthe homefront in Belgium. The 7-Steps PsychologicalSupport Plan is used to do this in a correct manner.

During the three years of effort (September 2006 untilMarch 2009), the Module BSRU was involved in severalcrisis interventions (demining incidents with (serious)physical injuries and even with lethal consequences,shooting incidents, road accidents with mass casual-ties,…). Individual psychological counselling was donewith several UNIFIL servicemen, with personnel of theLebanese Armed Forces personnel and even with membersof the local community.

Almost every member of the Centre for CrisisPsychology was involved in this UNIFIL mission. It was amission in which we had the opportunity to try out dif-ferent forms of psychosocial support. The continuouspresence of the module BSRU with a rotation every twomonths was evaluated as the most appropriate deploy-ment format.

REFERENCES

11. Government Policy statement and coalition agreement ‘Acreative and Solidary Belgium’(Jul 2003);

12. Strategic Plan MOD (Feb 2003).

13. Inter-Component Commitment Doctrine (Jun 2003).

14. Allied Joint Procedures AJP 4.10 (A).


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Luc Quintyn (†) - Cfr Acknowledgements.


15. MOD: The Belgian Deployment in Lebanon, VOX, DGIPR2006; 7, 1-6.

16. United Nations Interim Forces in Lebanon (UNIFIL).Background. United Nations Department ofPeacekeeping Operations, New York, United Nations,2006; 1-22. http://www.un.org/Depts/dkpo/missions/uni-fil/background.html

17. United Nations: Medical Support Manual for United NationsPeacekeeping Operations. United Nations Department ofPeacekeeping Operations, New York, United Nations, 1999.http://www.un.org/Depts/dkpo/medical

18. United News Center, New York, United Nations, 2February 2007. http://www.un.org/apps/news.

19. International Review of the Armed Forces MedicalServices, vol. 82/1, The contribution of the Belgian militaryclinical field laboratory to the United Nations MedicalFacilities deployed in Lebanon in 2006, 59-63.

10. MOD, DIRECT 2006/4, p. 7, Morele Bakens, Présent quandil faut.

11 MOD, DIRECT 2008/4, p. 2–5 – deel 1, Psychologische steunin operaties, Appui psychologique, Een open oor, Gérer lapeine.

12. MOD, DIRECT 2008/6, p. 10–13 – deel 2, Het psychosociaalplatform, Een luisterend oor, een steunende schouder,Platform psychosocial, Une oreille attentive, une épaulepour s’appuyer.

13. Briefing Chief of Staff, Kol E.Lapon, Transformation ofMedical support to Operations, NVKVV, 23 March 2009.

14. Field journal Module BSRU – BELUFIL.

15. BANCKEN, J, Mental Health and Well-being across theMilitary Spectrum, the RTO Human Factors Panel (HFM-205), Symposium in Bergen, Norway, April 2011.

www.rta.nato.int (Panel & Groups, HFM-205, Paper 40).

16. Biography Luc Quintyn, 2011. http://fr.wikipedia.org/wiki/Luc_Quintyn

17. BANCKEN, J, The Battle Stress Recovery Unit in Lebanon:A psychological module of the Medical Component, Bookof abstracts ESTSS, p. 39, 2009.

18. Project 1995-2002 - Convention between Ministry ofSocial Affairs, Ministry of Health and Environment andthe Ministry of Defence, 1995

Abbreviations

- ATLS: Advanced Trauma Life Support.- BELUFIL: Belgian Luxemburg Forces in Lebanon.- BSRU: Battle Stress Recovery Unit.- CC MED: Competention Centre Medical Component.- CCP: Centre for Crisis Psychology.- CME: Centre for Medical Expertise.- COps: Operational Centre of Defence.- CT: Contact team.- DCS: Damage Control Surgery.- EOD: Explosive Ordnance Disposal.- ICU: Intensive Care Unit.- LAF: Lebanese Armed Forces.- LL: Lessons Learned.- MC: Medical Component.- Mod: Module.- MOD: Ministry of Defence.- MTF: Medical Treatment Facility.- NEO: Non-combattant Evacuation Operation.- PEO: Peace Enforcement Operation.- PS: Primary Surgery.- PSO: Peace Support Operation.- PSP: Psychological Support Plan.- QAMH: Queen Astrid Military Hospital.- SPS: Specific Procedure.- UNIFIL: United Nations Interim Forces In Lebanon.

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By P. WONGCHERNTHAM�. Thailand

Pandit WONGCHERNTHAM

Air Evacuation of Cases of Botulism in Thailand.*

Group Captain Pandit WONGCHERNTHAM M.D.Appointment: Former Chief of AECC, RTAFStaff of Aviation Accident Investigation Board of Thailand.• Specialty: Psychiatrist of Neuro-Psychiatry Section.• Position: Operation officerQualification & Education: M.D. PMK Medical College.Board of Psychiatry, Siriraj Hospital, Mahidol UniversityAviation medicine instructor course from RAAF William, Adelaide, Australia Office: Institute of Aviation Medicine, RTAF.


ARTIC

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LES

RESUME

Evacuation aérienne de cas de botulisme en Thaïlande.

Nous rapportons l’histoire d’une épidémie de botulisme survenue en 2006 dans la province de Nan (à 668 km de Bangkok) enThaïlande. Il y eut 209 cas de botulisme identifiés dont plus de 130 furent admis à l’hôpital de Nan et 42 nécessitèrent une assistancerespiratoire.L’évacuation aérienne de masse fut pratiquée par l’équipe du Centre d’évacuations aéromédicales de l’Institut de Médecine aéronautique,RTAF. Le fait de prendre en charge un groupe aussi important de patients souffrant de paralysies respiratoires dans l’extrême nord de laThaïlande représentait une tâche ardue. Des renforts spéciaux en personnel et en équipement durent être recrutés dans plusieurshôpitaux de Bangkok. La mission s’est déroulée avec succès et l’évolution des patients fut très bonne. Tous purent rejoindre leur domicileet il n’y eut aucun mort dans cette série.

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KEYWORDS: Botulism, Outbreak, Aeromedical evacuation, Thailand.MOTS-CLÉS : Botulisme, Epidémie, Evacuation aérienne, Thailande.

SITUATION

In Ban Luang district of the Nan province, located in thenorthern part of Thailand on 14th March 2006, lunchwas served to over three hundred villagers with a localfavorite menu, one of which was the home-made bam-boo shoots preserved in metal containers. In that sameevening, a number of village men experienced abdomi-nal pain, nausea and vomiting, followed by one ormore of the following symptoms of ptosis, dysphagia,diplopia and breathing difficulty, in many cases, on thenext or further days.

Since the local doctors had experienced some sporadiccases of botulism in the past, food borne botulism wasdiagnosed. Initially, the patients were observed, admit-ted and treated symptomatically in the thirty - bed BanLuang community hospital. With increasing number ofpatients, most of them, including the more severe ones,

patients were referred to the nearby Nan ProvinceHospital (NH), a 450-bed general hospital which was 50kilometres further from the Ban Luang community hos-pital and the largest hospital of the Nan Province in thenorthern part of Thailand. By 21st March 2006, therewere a total of 209 botulism cases diagnosed, whichmore than 130 of them were admitted and 42 casesneeded mechanical ventilators.

RESPONSE

The Nan Hospital (NH) comprises of a 16 medical ICU bedsand an 18-bed step down unit. Working personnel inclu-ded 4 board certified internists and 5 rotating residents.

� Group CaptainInstitute of Aviation Medicine Royal Thai Air Force

* Presented at the 2nd ICMM Pan-Asia Pacific Congress on Military Medicine,Bangkok, Thailand, 27-30 November 2012.

Case of Botulism_WONGCHERNTHAM_Mise en page 1 13/03/14 18:27 Page1

During the early days of this medical casualty, attemptswere made by the local doctors in order to save and sta-bilize the intoxicated patients. Firstly, all essential medicalequipment, mainly respirators and ECG monitors, werecollected and borrowed from hospitals in Bangkok andnearby provinces to the Nan Hospital. The transportationwas facilitated by The Royal Thai Air-force (C-130).Secondly, the world renowned anti-toxins were acquiredfor administration to the patients at the earliest time.Fortunately, the anti-toxins could be obtained from com-panies in UK, USA, Canada and Japan. Most of the severecases received the 7-valent anti-toxin (A-G).

Dealing with such a big group of respiratory paralyticpatients in the far northern province of Thailand, refer-ral management was really a big task. Steps of mana-gement were urgently and carefully planned. Theseincluded severity assessment of patients, searching forappropriate referral hospitals and routes and methodof transportation.

Patients’ severity assessments included hemodynamicstability, spontaneous breathing ability and the presenceof complications (mainly pneumonia and hypoxemia).

Patients’ breathing was arbitrarily defined in 3 severitygrading according to his or her generated spontaneoustidal volume. Patients whose tidal volume of 0-50 ml.,50 < 150 ml., and ≥ 150 ml. were classified as severitygrade 1, 2, and 3 respectively.

Referral hospitals should therefore commit to theagreement of treating these patients in medical ICUs,university hospitals or university affiliated hospitalswere preferred in order to achieve the best outcome.

In northern Thailand, there is only one university hos-pital (in Chiangmai) and two university affiliated hospi-tal (in Lampang and Phitsanulok) which togetherwould be able to handle no more than 9 botulismcases. Therefore the majority of cases should be trans-ferred to a hospital elsewhere.

There were two main routes of transportation, by caror by air. Ambulance transportation by was restrictedto Lampang, Chiangmai, and Phitsanulok hospitalswhich were in the reachable distances of 227, 318, and295 kilometres from the Nan province respectively. Airtransportation was considered mainly for movingpatients to Bangkok.

Eight patients were successfully referred by ambulancesto the northern hospitals on 22nd March 2006(Lampang hospital 3, Chiangmai hospital 2 andPhianulok hospital 3). These were patients of severitygrade 1 and 2, four of whom had complete respiratoryparalysis, one had multi-lobar pneumonia and one hadasthma with early pneumonia. Seventeen patientswere transferred by plane on 23rd March 2006 and dis-tributed to a university or university-affiliated hospitalsin Bangkok (Ramathibodi hospital 3, Phramongkutklaohospital 3, Rajavithi hospital 3, Chulalongkorn hospital2, Siriraj hospital 2, Vajira hospital 2, and King

Bhumibol hospital 2). Though the patients in this groupwere rather sicker with severity grades mainly of 1-2(including 6 cases with complete respiratory paralysis),none of them had pneumonia, sustained hypoxemia orunstable hemodynamic status. These were consideredour essential pre-requisites for safety air transporta-tion. Provided the worst conditions of ventilator mal-functions on board, we hoped patients could stillbreathe safely by manual ventilation using self-inflatingbags.

On 22nd March 2006, an air evacuation of mass casualtyplan was carried out. The capability of the AeromedicalEvacuation Control Center to evacuate ICU cases is fourcases in a single trip. The ability of the C-130 aircraft toevacuate litter patients is 70 litters per 6 flight nurses.The C-130's standard configuration (AE-3) calls for 20litter spaces and allows for 34 ambulatory seats whichduring wartime operations can carry 29 litters with noambulatory patients. There is no therapeutic oxygensystem on board, and those patients who require oxy-gen must use portable oxygen tanks. Galley and toiletfacilities are typically simple and austere and may varyon different models of the C-130. Cabin noise makespatient evaluation difficult and inadequate lightningimpedes many patient care activities. The aircraft oxy-gen system needs to be supplemented by a self-contai-ned AE system for therapeutic oxygen delivery. The sin-gle lavatory is on the cargo ramp and is impossible forsome otherwise non ambulatory patients to use.During engine running on-load and off-load opera-tions at unimproved airfields, blown objects and dustcan present eye hazards and stress to crew andpatients.

Loading time for 20 patients in this event took aboutone hour. Flight time from the Nan Airport to Bangkok


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PATIENT TYPES MEDICAL ATTENDANTSREQUIRED

Ventilator Patients Physician, Critical Care Nurseand/orRespiratory TherapyTechnician

Trauma/Cardiac PatientsRequiringCardiac Monitoring

Advanced Cardiac Life SupportSystem CertifiedPhysician/Nurse

Psychiatric PatientsPosing a SafetyHazard to Themselvesor Others

Nurse or AppropriatelyTrained/Certified Medical Technician

Severe Burn Patient Physician or Nurse with BurnPhysiology Training

Any Patient RequiringClose MonitoringOne-on-One Care, orFrequent Medicationsor treatments

Nurse or AppropriatelyTrained/Certified Medical Technician

Patients requiring specialized care.


international airport is about one and a half hour. Thetotal time from on-load of the first patient in NanAirport to off- load of the last patient in Bangkok inter-national airport was about 3 hours.

Ambulatory Ventilators with self-contained AE systemfor therapeutic oxygen delivery were needed for eachpatient. Physicians, critical care nurses and/or respira-tory therapy technician were allocated to each patient.They came from Ramathibodi hospital,Phramonkuitkao hospital, Rajavithi hospital,Chulalongkorn hospital, Siriraj hospital, Vajira hospital,Lerdsin hospital and King Bhumibol hospital.Ambulatory Ventilators with self-contained system fortherapeutic oxygen delivery were supplied fromvarious hospitals; total summed 17. The incongruity ofventilators, connectors, and oxygen tanks of differentsources were a big problem.

Apart from the patients on board were 20 flight nurses,3 flight surgeons, 10 privates, air crews of C-130,Commanders of Royal Thai Air force, high rank officersof Ministry of Public Health.

Within the air craft, 5 tiers were prepared. Left tierswere settled with 3 litters. Right tiers with 2 litters. Forthe 3 litter tiers, the upper litter was for the patient. 2nd

litter for ventilators and medical equipment. The lowerlitter was for the patient. For 2 litter tiers, the upper lit-ter is for ventilators and medical equipment and thelower litter for the patient.

The position of ventilators, connectors and oxygentanks together with the severity and destination ofpatients were part of the information for the positioningplan.

Less severe patients stayed within the aircraft, whilemore severe patients were allocated near the ramp.The reasons are that the patients who are inside theaircraft must stay a longer time in the aircraft duringthe patient movement. In case of emergency, thesevere patients will be off loaded immediately.C-130 took off from Bangkok Airport at 0930 h and lan-ded at the Nan Airport at 1100h.

Under wings and under tail of the aircraft were used asareas to on load patients. Patient litters, ventilators andoxygen tanks litters were settled for loading in order.There were privates from both the Air Force and theArmy to transport the patients on board. A short courserefresh training on patient lift was done to prevent anyharmful incident.

At 1200 h loading of patients began. Patients weretransferred from the Nan hospital by ambulance usingself-inflating bags to the tents at the airport and werereceived by the medical team to prepare for flight andthen transfer to the aircraft. Ventilators and equipmentwere loaded respectively. Medical teams installed ven-tilators for the patients on the aircraft. At 1300 hpatient loading was complete and successful. The air-craft took off at 1330 h. During flight 2 ventilators did

not function properly therefore the medical team hadto use manual ventilation using self-inflating bags forthese patients.

The RTAF supported 2 flights of BT 67 to Bangkok Airportfor relatives of the patients, news reporter and others. At1500 h The C-130 landed at Bangkok airport. Off-load ofthe patients began. The ambulance from destinationshospitals awaited at Bangkok Airport. All patients andtheir relatives went to destination hospital safely.


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Under wings and under tail of the aircraftwere the areas to load patients.

Medical teams used self-inflating bagson both patients all the flight.


CONCLUSION

By the end of the 7th week, all hospitalized patientswere safely discharged home and there was no morta-lity in this series of 209 botulinum intoxicants. The toxinwas later identified and proved to be botulinum typeA. Since botulinum toxin has been mentioned as apossible future bio-weapon, our logistics in themanagement of this world largest food borne botu-lism outbreak may serve as a case study for thisdeadly condition.

ABSTRACT

This is a story about a botulism outbreak in the Nanprovince (668 kilometres from Bangkok), Thailand in

the year 2006. There were 209 botulism cases diagno-sed which more than 130 were admitted to the Nanhospital and 42 cases needed mechanical ventilatorysupport.

Air Evacuation of Mass Casualties was done by theAeromedical Evacuation Control Center team of theInstitute of Aviation Medicine; RTAF.Dealing with sucha big group of respiratory paralytic patients in the farnorthern province of Thailand, referral managementwas really a big task. Special aid including personneland equipment were recruited from many hospitals inBangkok. The mission was complete and successful andthe outcome of the patients transferred was very good.All patients were safely discharged home and therewas no mortality in this series.

VOL.87/1


Retrouvez toute l’actualité duComité International de Médecine Militaire

sur le site Internet :

Follow the current affairs of theInternational Committee of Military Medicine

on its website:

www.cimm-icmm.org


Mechanical Infusion Pump

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3rd Pan European Congress of Military MedicineBelgrade, Serbia

From 2 to 6 June 2014

Main Topics:• War Surgery (Civil War Trauma, Trauma Combat Casualty Care)• Basic Research in Trauma and Sepsis(Trauma and Sepsis Immunology, Trauma and Sepsis Genetics)• Update in Preventive and Veterinary Medicine(Update in Infectious Diseases, Food and Water Control)• Mental Health (Pre- and Post-Deployment Mental Health Assessment, Psychological Consequences of War Trauma)

Round Tables:• Military Medical Education in Europe• Management of CBRN Exposure• Update in the Military Medical Management and Supply

Plenary Session:• War Surgery and Traumatology• Research in Trauma and Sepsis• Update in Preventive and Veterinary Medicine• Mental Health

For more information: www.cimm-icmm.org

Annonce 3rd Pan European Congress Serbia 2014_Annonce 3rd Pan European Congress Serbia 2014 13/03/14 18:29 Page1

By A. FRITH. United Kingdom

Anthony FRITH

The Role of General Medical Practitioners inthe Care of Military Veterans with MentalHealth Problems.

Dr. FRITH graduated as a doctor form Liverpool University in 1973 and workedas a general medical practitioner in the North West of England from 1977 until

2011. He has been a Fellow of the Royal College of General Practitioners since2001, with whom he has collaborated on veteran’s mental health issues in primary

care. He was the clinical lead in mental health for Halton and St Helens Primary CareTrust from 2005 to 2011. During this time, he worked with a local veterans association to improve awarenessof veteran’s mental health issues within local primary care organisations.He currently works as a GP in New Zealand


ARTIC

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ARTIC

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RESUME

Rôle des médecins généralistes dans la prise en charge des anciens combattants souffrant de troublesmentaux.

Une étude qualitative a été menée auprès de neuf médecins généralistes britanniques pour examiner le rôle que pourraientjouer les médecins généralistes dans la prise en charge des anciens combattants souffrant de problèmes de santé mentale et quelen serait l’apport pour les anciens combattants.Les médecins généralistes perçoivent les anciens combattants ayant des problèmes de santé mentale comme des patients méritantset nécessiteux ayant des problèmes complexes. Leur prise en charge dans le cadre des soins de santé primaire est souvent freinéepar l’acceptation des soins de la part des anciens combattants, et par un accès insuffisant à des services spécialisés de qualité.Malgré ces limites, les médecins généralistes ont un rôle important en assurant une prise en charge holistique, centrée sur lepatient et sa famille. La collaboration avec les médecins généralistes ouvre des possibilités de dépistage de la maladie mentale,de gestion initiale des problèmes aigus, un soutien continu et une évaluation des risques.Les soins donnés aux anciens combattants pourraient être améliorés en confiant cette mission aux médecins généralistes. Ilsauraient besoin de plus de soutien dans l'organisation des systèmes d'information de manière à identifier les anciens combattants,et dune formation sur les problèmes spécifiques aux anciens combattants.

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KEYWORDS: GP, Mental health, Veterans, Primary care, United Kingdom.MOTS-CLÉS : Médecins généralistes, Santé mentale, Anciens combattants, Soins de santé primaire, Royaume-Uni.

INTRODUCTION

Definition of a veteran

Veterans include anyone who has served for at leastone day in HM Armed Forces (Regular or Reserve), aswell as Merchant Navy seafarers and fishermen whohave served in a vessel which was operated to facilitatemilitary operations by HM Armed Forces1.

The mental trauma of taking part in armed conflict hasbeen documented for many decades, but only recentlyunderstood. For instance, it has been documented that40% of soldiers in the Battle of the Somme suffered“shell-shock”2, but effective management and treatment

had to await defining and understanding of post-traumatic stress disorder. Much is now known aboutthe immediate and long term effects of conflict onserving soldiers and veterans. Most of this researchcomes from the USA. Yet the UK has a sizeable veteranpopulation, estimated to be 5 million3 and since 1945has been involved in over 20 conflicts. The main drivein UK research has come from the Kings Centre forMental Health4.

The gaps in the research concern how mental healthproblems in veterans are affected by different settingswhen they leave the services. Historically, research hasconcentrated on services that specialize in veteranscare.

MentalHealthProblems_FRITH_Mise en page 1 13/03/14 18:32 Page1

Little has been done looking at veterans care in the UKgeneral practice setting, even though most generalmental illness is currently managed in primary care5.What role do UK GPs have in veterans’ care? Do theyhave the skills and knowledge needed?

METHODS

This qualitative study looked at the views of experien-ced GPs using semi-structured, in-depth interviews withnine GPs in practice in the North West of England in2012.

GPs were chosen on the basis of experience as GPs anda track record of clinical leadership.

The interviews were semi-structured and tape recordedto be later transcribed into written text. In addition,field notes were written during or shortly after theinterviews, summaries of which were fed back to inter-viewees for comments.

Further analysis of the data from the interviews usedInterpretative phenomenological analysis

A constructivist model was taken in seeking to understandthe perceptions and lived experiences of general practi-tioners dealing with veterans’ mental health problems.

Observations about the strengths of the GP, the oppor-tunities for developing their role and how well equippedGPs are to take on the opportunities for care of veteranswere set against a background of the issues veteranspresent to GPs, and the limitations and boundaries to GPcare.

Each successive interview was influenced by themesthat emerged from the last interview.

RESULTS

Nine GPs practicing in the North West of England wereinterviewed. One GP was female, nearly all had been inpractice for at least 10 years (average = 19 years). Theirexperience varied from working as a GP trainer,Fellowship trainer, GP appraiser, to clinical and commis-sioning leads.

8 themes emerged from the interviews:1. Background experience of veterans as patientswithin the practice.*2. What was the experience of the GPs with veteranswith mental health problems as patients?3. What problems do veterans with mental health dif-ficulties present to the individual GP?4. What is the potential role for the competent GP inthe care of veterans?5. How should GPs process veterans’ mental healthissues that arise during consultations?6. How well equipped are GPs to deal with mentalhealth problems in veterans?7. What opportunities are there for GPs to be moreinvolved in managing mental health problems in veterans?

8. What are the limitations to the role of GPs andwhere do the boundaries lie?

There was considerable variation in the experiences ofthe GP interviewees in terms of the number of veteransthey had seen or were aware of in their practice (fromhardly any to quite a few) although not in their obser-vations about the nature of veterans’ problems or theinteraction with the GP. This was surprising, given thatthey were all above average GPs, in leadership roles,presumably from well organised practices, althoughthis observation could not statistically be extrapolatedto suggest the same variation in the wider populationof GPs, as this was a qualitative study with a statisticallysmall, unmatched sample. The interviewees thoughtthat this variation might be explained both by varia-tions in GP quality, and by the fact that even the bestpractices have to balance the needs of veterans withthe needs of other high risk groups competing forfinite resources, including the resource of GP time andinterest.

“From a vet’s point of view I think it varies quite a bitby practice…I’ve talked to other doctors who are not really interested,quite frankly… I suspect vets get a different responsefrom different surgeries”

What is very clear is that GPs view veterans as a needy,hard to reach group within their practice population.They are deserving of help, both because they are anat-risk group with above average levels of distress andproblems, and also because GPs have a fundamentalrespect for their veteran status. That respect, in thoseGPs interviewed, was partly because of direct expe-rience of caring for veterans, and also because of asense that the community that GPs belonged to owes alot to those who serve their country in war.

“I assume they are tough individuals. Quite frankly, Ienjoy talking to these people - they’re interesting, theyhave some interesting stories… But get it wrong firsttime – whatever you’ve said, done, organised – theywill disappear - that’s what they’re like as people”

“I do sympathise, I do understand as a member ofsociety the role of veterans and the sacrifice thatthey’ve made”

Yet, evidently narrated by those interviewed, mana-ging mental health problems in veterans presents signi-ficant challenges for the GP, and whilst this can some-times be very rewarding, more often it is frustrating.That frustration, in the view of the GPs, was partly dueto the complexity and severity of the problems, espe-cially in the interplay between armed service expe-rience, individual veteran personality, social, psycholo-gical and physical illness factors. Alcohol and substancemisuse significantly worsened the chance of successfulintervention within primary care and within specialistservices, as did negative attitudes by veterans towardssuch interventions – most noticeable with attitudestowards psychological and alcohol interventions.


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“With the cases that I’ve dealt with there has certainlybeen substance misuse, particularly alcohol has been afeature and that has been more complicated tomanage”

On the fundamental question of what care GPs couldand should provide, there was a wide range of ideas. Acentral theme to this was that core GP qualities of holis-tic care, good listening skills, empathy and a patient-centred, rather than disease-orientated, approach hasmuch to offer for veterans. The GPs felt that patienttrust and respect were generally high, and that theywere a first point of contact for veterans and theirfamilies. Indeed, the fact that families had easy accessto the GP was often the only way problems in veteranscame to light.

“[my role as a GP with veterans is] firstly to hear thestory, what are they actually saying, try and help themunderstand what it is they are saying, being listened toand taken seriously – if you haven’t communicatedthat, you’ve lost it”

There was a strong feeling that there was a considera-ble opportunity to use the highly effective IT systemswithin practices to identify veterans within the GPconsultation so as to target appropriate care andscreen for mental health problems. The difficulty high-lighted was that this would need considerable organi-sation within practices and by outside agencies such asgovernment, although none of the interviewees saidthis was unachievable.

“You’ve got to have it coded [being a veteran]… themost fundamental way of providing proactive healthcare is to have a system that identifies people at riskand doing something about it“

Many of the GPs felt that they had a significant roleonce mental health problems had been identified -more than just signposting to more specialised services.Most felt that some initial management of developingmental health problems within primary care was possi-ble, along with on-going support and risk assessmenteven when veterans had been referred. As there was ahigh default rate in those referred, and a feeling withsome GPs that specialist services were not very good oraccessible, the problems often returning to the GP any-way. An exception was post-traumatic stress disorder,which usually triggered early referral, as GPs felt theyhad limited skills in this area.

“There is a tendency to read this as ‘they’ve got specialneeds, you must refer them on, they’ve got a fast trackservice,’ which may be true, but I would rather givethem a dose of ‘GP’first. You feel patients appreciatethat and especially veterans”

One important theme to emerge as the interviews pro-gressed was that the role of GPs in the care of veteranswas not confined to the consultation room. GPs havean important role as advocates for veterans, both forindividual patients and collectively for all veterans in

their practices. For some GPs, this meant writing letterson behalf of patients for housing or benefits. Forothers, it meant actively complaining where there wasa perceived lack of access to, or poor quality of, specia-list and psychological services. Often this was by directcontact with those services. Most of the intervieweesacknowledged the growing role of GPs in commissio-ning health care and saw that as an opportunity tocommission for improved access to quality services forveterans.

“The issue of hard to reach and vulnerable people isway up the agenda [in commissioning]`”

Although the interviews highlighted opportunities forGPs to develop the role they and their fellow GPs couldplay in the care of veterans with mental health pro-blems, there were important limitations noted, inclu-ding lack of time, lack of training of GPs in veteransissues, patchy GP skills in dealing with mental healthproblems generally and lack of professional peer sup-port. Other limiting factors included lack of informa-tion about which patients in the practices were vete-rans, and reluctance, by a significant proportion ofveterans, to accept the help GPs could give.Although some GPs were conscious of fixing bounda-ries to their role so that they did not have to step out-side their level of competence, many felt that one ofthe strengths of general practice was the great flexibilityin the boundaries of GP care. How far the GPs viewedtheir role varied considerably from GP to GP, but in theend it was often the veterans themselves who definedthe boundaries.

“I am here to be used when I am useful. There’s oneparticular chap who sees me very intermittently... whowill appear from time to time, we will have a modera-tely long discussion about where he’s up to, and thenhe’ll disappear again. In no sense is he dependent onme, but I suspect that he finds me a moderately usefulsounding board from time to time”

DISCUSSION

The role of the UK National Health Service in the healthcare of veterans has been increasing since the end ofWorld War 2.

Priority treatment for veterans whose illness was cau-sed by their time in the services was introduced in 1953and was extended in 2007.

Despite this, a survey in London as recently as 2008 sho-wed that there were over a thousand homeless vete-rans on any night6. The NHS Operating Frameworksfrom 2008 onwards placed specific emphasis on strate-gic health planning for veterans7. The Royal College ofGPs has produced an advice leaflet for GPs8.

There are gaps in the research about how known men-tal health problems are affected by different settingsthat veterans find themselves in when they leave thearmed services


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Historical and current research has concentrated onresearch done by services that specialize in veteranscare, such as the United States Department of VeteransAffairs and the King’s Centre for Military HealthResearch in the United Kingdom

The purpose of this research was not to get a consensusabout how GPs manage veterans with mental healthproblems, but rather to broaden the range of ideasabout how primary care might contribute to vete-rans’care. The research makes no comment about thequality of current services provided by GPs. This is thefirst qualitative study known to the author of the expe-riences and views of professionals working within pri-mary care about veterans presenting with mentalhealth problems, so it gives an insight into GPs attitudestowards veterans.

It explores opportunities for GP care, against a back-ground of the difficulties faced by GPs and the limitationsand boundaries in their professional role as a key mem-ber of the primary care team.

This study demonstrates that GPs themselves view vete-rans with mental health problems as a deserving andneedy group. Although sometimes satisfying to workwith, veterans often have a complex mix of psychologi-cal, social and physical problems, and managementwithin primary care is often frustrated by the care thatveterans will accept and by inadequate access to highquality services. Alcohol problems play a big part in themental health issues and significantly influences whatcan be done for veterans.

Never-the-less, the GPs interviewed felt that they had asignificant role to play, not least by providing goodquality, holistic, patient-centred care in a family orien-tated practices, with good primary care to families ofveterans, in addition to early recognition of developingproblems when family members reported issues thatveterans themselves were reluctant to seek help for.

Those interviewed saw considerable opportunities for thefuture by improving systems to identify and highlightveterans, and by a developing advocacy role. Care of vete-rans in the future could be enormously improved byGPs’involvement in commissioning, which at the very leastcould improve access to high quality specialised services.

CONCLUSIONS AND RECOMMENDATIONS

Those interviewed saw considerable opportunities forthe future by improving systems to identify and high-light veterans, and by a developing advocacy role. Careof veterans in the future could be enormously improvedby GPs involvement in commissioning, which at the veryleast could improve access to high quality specialisedservices when necessary.

GPs need more support in the organisation of informa-tion systems to identify veterans. They need appro-priate training in managing mental health problems ingeneral, and in veterans’issues in particular.

Their role in commissioning services for veterans withmental health problems needs highlighting, encoura-ging and supporting, as do other advocacy roles GPshave for their veteran patients.

GPs have well recognised holistic skills, which are sub-ject to regular scrutiny and benchmarking. To make thebest use of opportunities to develop the role of the GPin the care of veterans with mental health problems,those current skills need recognising and highlighting.

COMPARISON WITH LITERATURE

Much is known about the mental health problems suf-fered by veterans. The experiences of the GPs in thisstudy correlate with literature studies on veterans, forinstance the difficulties veterans experience in familyand partner relationships9 10, the reluctance of veteransto seek help11, 12, the negative impact of military cul-ture13, 14, the influence of alcohol, 15 the mental healthlegacy from conflicts many years ago16, 17, 18.

Previous authors have stated that the key strengths ofgeneral practice lie in the doctor-patient relationshipand holistic care skills19, within a setting that is cost-effective, based on local population priorities20. TheGPs in our study demonstrated the clinical and inter-personal effectiveness of general practice that has beenwell documented by others21. They recognized thevalue of the ‘non-specific healing effect’ of theirconsultations, as described by previous authors22.

Literature about mental health problems in the commu-nity has been biased by specialist psychiatry. Gask arguedthat primary care mental health research is in its infancy,and more is needed to look at primary care across thefull spectrum of mental health problems23. Our researchadds the GP care of veterans to that spectrum.

LIMITATIONS OF THE STUDY

This study looked at the viewpoint of GPs and fills a gap inthe knowledge base about GP care of veterans. Future stu-dies could combine the views of primary care professionals,especially GPs, with the views from outside the profession,including politicians, health care managers and veteransthemselves. Studies that combined the views of GPs andfamily members caring for veterans with mental healthproblems would be particularly helpful.

This study was a qualitative study. Its strength is that itgathered the views of GPs in leadership roles, but afuture quantitative study might be of additional use tohealth service planners.

The sample selection was carefully planned and in theend proved sufficient for the outcome, but alternativesample methods could have been used and might havebeen more effective. There was only one female inter-viewee. Although there was no attempt to look at thedifference between male and female GP’s views, ahigher proportion of female GPs might have expandedthe range of ideas expressed.


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HOW THIS STUDY FITS IN

There is evidence from the literature that veterans havecomplex mental health problems that are not beingfully met by current services. There is a lack of researchabout the views of GPs about the care of veterans. Thisstudy is the first qualitative study on GPs’perception oftheir role and highlights how that could contribute toimproving care for veterans.

Although this was a study of British GPs, it has rele-vance to primary care workers in all countries that havesignificant veterans’mental health issues.

SUMMARY

A qualitative study was conducted on nine British GPsto look at the potential role of GPs in the care of mili-tary veterans with mental health problems and howthat might add to the help available for veterans.

GPs view veterans with mental health problems as des-erving and needy patients who have complex pro-blems. Management within primary care is often frus-trated by limitations to the care that veterans willaccept, and inadequate access to quality services torefer to.

Despite these limitations, GPs have a significant role toplay by providing holistic, patient-centred care andfamily-centred primary care. Contact with GPs providesopportunities to screen for mental illness, initial mana-gement of acute problems, on-going support and riskassessment.

The care of veterans could be improved by using GPinvolvement in commissioning.

GPs need more support in the organisation of informationsystems to identify veterans, and training in veterans’issues.

REFERENCES

11. UK Department of Health. (2009) For those who served: Meetingthe healthcare needs of veterans in England. Available fromhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_108517 [accessed 9/6/12].

12. MACLEOD, A. (2004) Shell shock. Journal of the RoyalSociety of Medicine 2004 February, 97 (2): 86-89. Cited inMental Health Foundation (2010). Need 2 know: the men-tal health of veterans - executive briefing. Available fromhttp://www.mentalhealth.org.uk/publications/need2know/ [accessed 7/5/11].

13. KITCHINER, N. (2009) A community NHS mental health ser-vice for veterans of the armed services. Available fromhttp://webcache.googleusercontent.com/search?q=cache:Lx56VUs0EwwJ:interactivemediainstitute.com/down-loads/WOWIIPo [accessed 5/5/11].

14. DANDEKER, C. WESSELY, S. (2005). The King’s Centre forMilitary Health Research. Available from

http://www.publicservice.co.uk/article.asp?publication=Health&id=195&content_name=Physical%20and%20Mental%20Health&article=4877 [accessed 20/3/11].

15 HODGES, B. et al. (2001). Improving the psychiatric know-ledge, skills and attitudes of primary care physicians 1050– 2000: a review. American Journal of psychiatry. 2001;158: 1579-1586.

16. JOHNSEN, S. et al. (2008). Effectiveness of interventions inpreventing rough sleeping and homelessness among ex-service personnel in London Available fromhttp://www.york.ac.uk/inst/chp/Projects/homelessexser-vice.htm [accessed 15/3/11].

17. UK NHS Operating Framework 2009 – 2010.Available fromhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digi-talassets/@dh/@en/documents/digitalasset/dh_091446.pdf[accessed 24/11/10].

18. RCGP. (2010). Meeting the healthcare needs of veterans: aguidance for general practitioners Available fromhttp://www.rcgp.org.uk/policy/key_rcgp_documents/healthcare_needs_of_veterans.aspx [accessed 20/3/11].

19. WOODHEAD, C. et al. (2011). Mental health and healthservice use among post-national service veterans: resultsfrom the 2007 Adult Psychiatric Morbidity Survey ofEngland. Psychological Medicine (2011), 41: 363-372.

10. SAYERS, S. et al. (2009). Family problems among recentlyreturned military veterans referred for a mental healthevaluation. Journal of Clinical Psychiatry. Feb 2009, vol/is70/2: 163-70.

11. FASOLI, D. et al. (2010). Predisposing characteristics,enabling resources and need as predictors of utilisationand clinical outcomes for veterans receiving mental healthservices. Medical Care, April 2010, vol/is 28/48/4: 288-95.

12. LINDLEY, S. (2010). Monitoring mental health treatmentacceptance and initial treatment adherence in veterans:veterans of Operations Enduring Freedom and IraqiFreedom versus other veterans of other eras. Annals ofthe New York Academy of Sciences. Oct 2010, vol/is 1208:104-13.

13. STEKER, T. et al. (2007). An assessment of beliefs aboutmental health care among veterans who served in Iraq.Psychiatric Services. Oct 2007, vol/is 58/10: 1358-61.

14. COOPER, J. et al. (2007). Mental health initiatives for vete-rans and serving personnel. Medical Journal of Australia.Oct 2006, vol/is 185/8: 453.

15. LEWIS, G. (2010). Mental health of UK Afghan and Iraqveterans. The Lancet. May 2010: vol/is 375/9728: 1758-61.

16. BROOKS, M., FULTON, L. (2010). Evidence of poorer life-course mental health outcomes among veterans of theKorean War cohort. Age & Mental Health, March 2010,vol/is 14/2: 177-83.

17. VILLA, V. HARADA, N. (2002). Health and functioningamong four eras of U.S. veterans: examining the impact ofwar cohort membership, socioeconomic status, mentalhealth and disease prevalence. Military Medicine.September 2002, vol/is 167/9. VOL.

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18. O’TOOLE, B. et al. (2010). The mental health of partners ofAustralian Vietnam veterans three decades after the warand its relation to veterans military service, combat andPTSD. Journal of Nervous & Mental Disease. Nov 2010,vol/is 198/11: 841-5.

19. LLOYD, D. (1994) Joint Working Party of the WelshCouncil of the Royal College of General Practitioners andthe Welsh General Medical Services Committee (1994).Patient care and the general practitioner. BMJ. 1994, 309:1144.

20. STARFIELD, B. (1998). Primary Care: Balancing healthneeds, services and technology. Oxford University Press.Cited by King’s Fund (2011) Improving the quality of care

in general practice: report of an independent inquirycommissioned by the King’s Fund. Available fromhttp://www.kingsfund.org.uk/publications/gp_inquiry_report.html [accessed 11/5/11].

21. HOWIE, J. et al. (2006). Quality, core values and generalpractice consultation: issues of definition, measurementand delivery. Family Practice. 2004; 21: 458-468.

22. DIXON et al. (1999). The physician healer: ancient magicor modern science. British Journal of General Practice.1999, vol/is. 49/441: 309-312.

23. GASK, L. et al. (2009). Primary care mental health. RCPsychPublications.


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Deadline for Abstracts: 30 June 2014

4th

ICMM Pan-Arab Regional Working Group Congresson Military Medicine

King Hussein Bin Talal Convention Center

Dead Sea - Jordan

4 - 7 November 2014

For further informations, inquiries about registration and abstracts submission, you can visitThe Royal Medical Services website:

w w w . j r m s . g o v . j oor

w w w. c i m m - i c m m . o r g


By A. K. AL-ASMARI� and M. DEBBOUN�. Saudi Arabia

Abdulrahman Khazim AL-ASMARI

Scorpions of Military Importance in Saudi Arabia:Morphological Characteristics, Clinical Profile andManagement.*

Senior consultant in Clinical biochemistry (toxinology).Director of Research Center at the Prince Sultan Military Medical City (PSMMC),

Medical Services Department, Ministry of Defense, KSA.Member of the Research and Ethics Committee PSMMC.

EDUCATION

PhD in Clinical biochemistry, Department of Chemical Pathology, Medical College at St Bartholomew, Universityof London in 1996.M Phil, Proteomic studies of snake venoms and their biological activity, University of London UK in 1994.Diploma in Environmental Pollution Research, National institute of Standards Technology, Maryland USA. 1992-1993.Masters in Toxicology in 1991 from KSU Riyadh.Diploma in Clinical pharmacy from London Royal Hospital UK 1988.Bachelor’s degree in Pharmacy from the King Saud University in 1983.

RESEARCH ACTIVITIES

Dr. AL-ASMARI is known for his scientific contributions in the field of toxinology, and immuno toxinology andin the management of scorpion stings and snake bites. He is one of the few scientists who have undertakena comprehensive survey and characterized the scorpion and snake fauna of the different regions of theKingdom of Saudi Arabia (KSA).He is an active researcher and has published his research work in reputed international and national journalsand is the author of books and book chapters published by International publications of repute.He has been awarded research projects including national projects by different sponsoring agencies in KSA.At present he is undertaking research projects to study the natural toxins such as the venoms of scorpion andsnakes and their different fractions for their therapeutic potential in treating different diseases including cancer.Dr. AL-ASMARI has many firsts to his credit. He was the first Saudi researcher who developed specific ovineantivenom against some of the most poisonous snakes of Saudi Arabia, and has also undertaken phylogeneticstudies to identify different scorpion species.His contributions in this field have been acknowledged by the authorities in the Ministry of Health, Ministryof Defense and Governorates of different regions of Saudi Arabia.Dr. AL-ASMARI is a member of the Editorial Board of many journals and of prestigious national and internationalscientific societies and committees.


ARTIC

LES

ARTIC

LES

RESUME

Scorpions d’importance militaire en Arabie Saoudite : caractéristiques morphologiques, profil cliniqueet prise en charge.

La piqûre de scorpion fut la cause d’envenimation la plus fréquente parmi les troupes stationnées en Arabie Saoudite durant larécente guerre du Golf Arabo Persique. Les scorpions responsables de ces piqûres appartiennent aux familles Buthidae,Scorpionidae, et Hemiscorpiidae. Une manifestation typique de piqûre de scorpion peut être caractérisée par une douleur atroce,avec érythème marginal, oedème, inflammation, hypotension, salivation, priapisme, tachycardie, hypertension, perspiration,nausées, céphalées, et crampes musculaires. Une envenimation sévère peut aboutir à une cytotoxicité, une neurotoxicité et unetoxicité respiratoire et cardiaque qui peut engager le pronostic vital. La majorité des patients peuvent être traités par des analgésiques,une application locale de glace, accompagnés d’un traitement symptomatique. L’usage de sérum antivenimeux est réservés aux cassérieux, avec manifestations systémiques. L’identification du scorpion peut aider à choisir la stratégie de traitement. Les mesurespréventives, incluant le retournement des bottes avant de se chausser, l’inspection des vêtements avant de s’habiller et le rangementdes sacs de couchage étroitement roulés peuvent réduire le nombre de piqûres de scorpions.

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KEYWORDS: Scorpion Stings, Saudi Arabia, Military.MOTS-CLÉS : Piqûres de scorpions, Arabie Saoudite, Militaires.

Scorpions_DEBBOUN_Mise en page 1 13/03/14 18:34 Page1

INTRODUCTION

Scorpions are one of the oldest known terrestrialarthropod animals of the order of the Scorpiones withthe class Arachnid. Fossils of scorpion found inPaleozoic strata 430 million years old closely resembleto the present day species of scorpions. Their stingcontains pair of poisonous glands which can paralyzeprey, usually insect or rodents or may deliver a painfulsting to un- cautious person which may be deadly insome cases. Scorpions have been of great militaryimportance in past as a biological warfare, the fact thatnearly 2,000 years ago, live scorpions were used by theParthians as military weapons in the form of «scorpionbombs». Perhaps it was the ancient version of today’sland mines to prevent the advancement of enemy.Terracotta pots have been found at the desert fortressof Hatra near modern Mosul, Iraq, where scorpionbombs were used to successfully repulse Roman besie-gers in 198 AD1, 2.

Scorpion stings (scorpionism) are the most importantcause of arachnid envenomation and are responsiblefor significant morbidity and mortality in many parts ofthe world. Envenoming by scorpion poses a great envi-ronmental hazard in the Middle or Far East countrieswith annual incidence ranging from 16 to more than1,000/100,000 yearly3, 4. The dispersal of a large militaryforce throughout the eastern Saudi Arabian desertduring the early months of the United Nations’ res-ponse to the Iraqi invasion of Kuwait and inAfghanistan during the recent conflict reiterated theconcern about the relative danger presented by snakesand scorpions5. The annual incidence among Americantroops stationed in Saudi Arabia during the operation«Shield of the Desert» was estimated at 2,400 scorpionstings per 100,000 soldiers6. Scorpion stings can inflictsevere physical, psychological, and economic stress thatmay threatens the military mission with devastatingresults7.

Morbidity and mortality from the bites and stings ofvenomous animals can cripple even the best trainedarmies. Therefore, it is essential that preventive medi-cine teams remain vigilant on a global basis. Militarymedical entomologists have a long and proud historyof ‘serving those who serve’and will continue to reducethe impact of these creatures on the health ofdeployed personnel. During Desert Shield/Desert Stormoperations, military entomologists were present inSaudi Arabia and in Iraq and Afghanistan supportingOperations Iraqi Freedom and Enduring Freedom.Besides providing information about the possible bio-logical hazards to the commanders, military entomolo-gists provide equipment and expertise for vectorcontrol and assist in providing training about preven-tive methods and improving living conditions8.

In this review, we describe the morphological characte-ristics, clinical presentation and sting management ofsome of the important poisonous scorpions in the SaudiArabian Peninsula. The information provided in thisarticle may be used as guideline for the prevention and

treatment of scorpion sting among local population aswell as military personnel stationed in this region.

VENOMOUS SCORPION SPECIESOF MEDICAL SIGNIFICANCE

There are about 1,500 different species of scorpionsaround the world. Only small proportions of these scor-pions (about 50) are medically important and dange-rous to humans9, 10. Majority of the scorpion species arefound in tropical and sub tropical regions. Generallythese species prefer to live in deserts, forests and prai-ries. Accidental human stinging occurs when scorpionsare disturbed while in their hiding places, thereforemost of the stings occur on the hands and feet.

A total of 28 species and subspecies of scorpions belon-ging to Buthidae, Scorpionidae, and Hemiscorpiidaefamilies have been reported from Saudi Arabia11.Although all scorpion species are poisonous, there are7 species of scorpions in KSA which are of medicalimportance due to the severe toxicity of their venoms.Five of these species belong to the family Buthidae, onespecies each to the families Scorpionidae andHemiscorpiidae. The geographical distribution of medi-cally important scorpions in Saudi Arabian region isgiven in Table 1.

BUTHIDAE

The family Buthidae, with 89 genera and over 991 spe-cies, is the largest and most widespread of the scorpionfamilies12, mostly found in tropical, subtropical and partlyin temperate habitats. The members of this family aresmall and medium sized scorpions generally with a trian-gular sternum but some genera have a pentagonal ster-num. In many genera including Androctonus,Apistobuthus, Parabuthus, and some Old World generathe cauda is usually strong and powerful and the pedi-palps are often very slender whereas other genera haveelongate appendages, especially in males (e.g.,Centruroides, Lychas, Isometrus and related genera).Most of the species are yellow or brown (or variations ofthese colors), but black forms are also present. Some scor-pion species of this family have quite intricate and attrac-tive patterns (e.g., Lychas and Isometrus) and colours(e.g., Centruroides and Uroplectes). Size of the scorpionsof this family range from about 20 mm (like Microtityusand Microbuthus) to over 120 mm (as in Androctonus,some Centruroides, Apistobuthus and others). Its mem-bers occupy all faunal regions, but the greatest genericdiversity occurs in the Old World, especially in the Afrotropical region (22 genera) and in southern portions ofthe Palaearctic region (23 genera).


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� Research Center, Prince Sultan Military Medical City,Riyadh, Kingdom of Saudi Arabia.

� Department of Preventive Health Services,Academy of Health Sciences, US Army Medical Department Center & School,3599 Winfield Scott Road, Fort Sam Houston, TX 78234, USA.

* Presented at the 3rd ICMM Pan-Arab Congress on Military Medicine,Abu Dhabi, United Arab Emirates, 9-13 December 2012.


Several species in this family are highly toxic, but fewerthan 20 can be lethal to man. The most notorious spe-cies are found in the genus Androctonus, Centruroides,Hottentotta, Leiurus, Parabuthus and Tityus. Scorpionsfrom the Buthidae family are involved in severe enve-noming around the world13, 14 sometimes resulting infatalities. Unlike most other scorpion families, theButhidae are of both scientific and public interests dueto their medical importance in many parts of the world.Twenty-two of the 28 scorpion species of Buthidaefamily have been reported from Saudi Arabia, of whichfive are medically important. Morphological characte-ristics of these five scorpion species along with distri-bution in KSA, manifestations following sting havebeen described below:

Androctonus crassicaudaThis is a moderately large dark fat-tailed scorpionwhich grows up to 4 - 9cm in length. Body is heavy,usually dark brown in color (often nearly black), butexists in several colors with the color ranging from olivebrown to reddish brown to black, with 4 or more dor-sal, longitudinal ridges with serrate crests on most seg-ments of the post-abdomen, and numerous short, stiff,dark hairs and spines scattered over body and post-

abdomen. Pedipalps (pincers) are large, robust at baseand generally fearsome-looking with a re-curved sting attip of post-abdomen (telson). It is a nocturnal scorpionand mainly found in margins of desert, arid, semi-aridsites with sandy surface soil; sometimes it is also found inaccumulated vegetation debris, or in rock crevices15.

This species is widely distributed across Saudi Arabiaand has been reported from Al-Gunfuda, Aseer, EasternRegion, Hafr Al-Batin, Hail, Jazan, Mecca, Al-Medina,Najran, Quassiem, Riyadh, and Tabuk regions16.

A. crassicauda is one of the top three most poisonousscorpions in the world with extremely virulent venom.The venom of this species has neurotoxic, cardiotoxic,and myotoxic factors. Effects of envenoming (sting)usually include immediate severe local pain, rednessand swelling; in addition to delay (from one to 24+ hours later) systemic effects which may involve heartmalfunctions, remote internal bleeding and problemswith vision and breathing. Human deaths reportedlymost often due to respiratory arrest, heart failure, orshock17.

Scorpion sting was a major issue during the entireArabian Gulf conflict throughout the theater.Androctonus crassicauda was the most prevalent spe-cies responsible for scorpion sting, especially when theystaged "scorpion fights" as entertainment. Ironically;the venom of this species has yielded a drug that ishelpful to stroke victims18.

Androctonus bicolorThis species grows up to 8 cm long, Body is usually verydark brown to black, with end of the legs and fingerspaler. The females have 20 to 27 teeth and males 27 to32 teeth. The terminal segments of legs and pedipalpiare lighter yellowish-brown like A. crassicauda. Postabdominal segments have two and three well develo-ped median lateral keels with few granules19. Pincersare not as robust at base as those of A. crassicauda. It isnocturnal, and found hiding in crevices during the day.Mainly found in arid, semi-arid or margins of desertsites, usually with sandy soil. This species is widely dis-tributed in several countries of the Middle East. InSaudi Arabia it has been reported from Aseer, Hail,Najran, Quassiem, Riyadh, Tabuk, and also from theEastern region.


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Androctonus crassicauda.

FAMILY SPECIES DISTRIBUTION

BUTHIDAE Androctonus amoreuxi Androctonus crassicauda

Androctonus bicolor

Androctonus australisLeiurus quinquestriatus

Al-GunfudaAl-Gunfuda, Aseer, Eastern Region, Hafr Al-Batin, Hail, Jazan, Mecca,Al-Medina, Najran, Quassiem, Riyadh, Tabuk Aseer, Eastern Region, Hail,NajranQuassiem, Riyadh, Tabuk Al-Gunfuda, Aseer, Al-Medina Al-Baha,Al-Gunfuda, Aseer,Eastern Region, Hail, Mecca, Al-Medina, Najran, Riyadh, AttaifJazan, Tabuk

SCORPIONIDAE Nebo hierichonticus Al-Baha, Aseer, Attaif, Jazan, Al-Medina, Najran, Tabuk

HEMISCORPIIDAE Hemiscorpius lepturus Riyadh

Table 1: Some common medically important scorpions from Saudi Arabia.


The venom of this species has neurotoxic, cardiotoxicand myotoxic factors and comparable in potency to thevenom of A. crassicauda. Effects of envenoming (sting)usually include immediate severe local pain, rednessand swelling; plus delayed (from one to 24 + hourslater) systemic effects which may involve cardiacarrhythmias and cardiac failure and hypovolaemichypotension due to fluid loss through vomiting andsweating.

Androctonus australisThis species can grow to about 5 – 8 cm long. Body isheavy, usually medium to dark brown in color, with yel-lowish brown legs and black tips of pincers and a blacktelson; each post-abdomen segment has 4 dorsal ridgeswith serrate crests. Numerous short, stiff dark hairs andspines are scattered over the body. Pincers (pedipalps)

are large, robust at base with a generally fearsome-loo-king, re-curved spine at tip of the tail. Geographically itis one of the most wide-spread species in this genus. Itis nocturnal in habit and hides in crevices during theday but can also climb most vertical surfaces very well(to > 20 ft. above ground)20. Found mainly in marginsof deserts or very arid places across most of the Middle-Eastern countries. In Saudi Arabia it is widely distributedin the Al-Gunfuda, Aseer and Al-Medina regions.

The venom of this species is mainly neurotoxic withadditional cardiotoxic, myotoxic and hemotoxic fac-tors21. The venom is more potent than any of the spe-cies in this genus and often affects several body organsand systems of humans; human deaths due to thestings of this species are reportedly due to respiratory orheart failure; sometimes cerebral hemorrhage, criticalorgan dysfunction, or shock may also be involved21.

Androctonus amoreuxiThis species grows up to 4.5 - 7cm long and is very simi-lar in size, appearance and physical characters of A.australis and A. crassicauda but can be differentiatedfrom them by a narrow and light color of the terminalmetasoma, and a less bulbous pedipalp than A. australis.Metasomal segments are yellow, usually paler than cara-pace and tergites with keels slightly reddish. Pedipalps,sternites, and legs are also of a pale yellow color. Telsonvesicle is ochre yellow or dirty yellow. Aculeus is yello-wish basally and becoming reddish towards the tip.This species is mainly found in arid, semi-arid or mar-gins of desert sites, usually with sandy soil. It is noctur-nal, hides in crevices and under various objects duringday21.

It is widely distributed in the Middle East, NorthernAfrica and Al-Gunfuda region of Saudi Arabia16, 22. Thetypical habitat is closely related to other species of thisgenus (e.g., Androctonus crassicauda).


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Androctonus bicolor.

Androctonus australis. Androctonus amoreuxi.


The venom of this species mainly consists of neurotoxic,cardiotoxic and myotoxic factors. Effects of envenoming(sting) usually include immediate severe local pain, rednessand swelling; plus delayed (from one to 24 + hours later)systemic effects which may involve cardiac arrhythmias andcardiac failure and hypovolaemic hypotension due tofluid loss through vomiting and sweating18, 20.

Leiurus quinquestriatusThis species grows up to 3 – 7.7cm long. Body is usuallypale yellow-brownish (sometimes with greenish tinge),cephalothorax is darker (brownish or gray-brown) thanlegs and post-abdomen, 5 dorsal longitudinal keels areseen on top of the first 2 abdominal segments, and the5th post-abdominal segment (next to the telson) is dis-tinctly darker than remainder of abdomen and legs.Legs and post-abdomen have many strong, erect hairsand spines; pincers are relatively long and thin. It iscomparatively lightly built compared to other scor-pions, with a long thin tail and slender pedipalps(claw). The dark segment on the tail is sometimes faintor even missing, which can complicate identification.

Mainly found in dry habitats (deserts) on various subs-trate surfaces but not in loose-sand dunes, and notcommon near towns, nor near (nor in) houses. It isoften found hiding in small natural crevices, burrows,under stones, etc. This species is widely distributed inSaudi Arabia and reported from Al-Baha, Al-Gunfuda,Aseer, Eastern Region, Hail, Mecca, Al-Medina, Najran,Riyadh, Attaif, Jazan, and Tabuk regions16, 23, 24, 25 andhas also been reported from all the countries in theMiddle East18.

It is considered as a highly dangerous scorpion withvery potent venom which is a powerful cocktail of neu-rotoxins. The sting from this scorpion is extremely pain-ful with a high risk of anaphylaxis, a potentially lifethreatening allergic reaction to the venom. The sting fromthis scorpion has been reported to result in numeroushuman deaths annually21.

SCORPIONIDAE

This family consists of 18 genera and 276 species (2genera and 2 species are extinct), some of the world’slargest scorpions belong to this family, and because ofthis some members of this family are very common inthe pet industry (e.g. Pandinus imperator andHeterometrus spp (The scorpion files). The largest spe-cies known thus far are Heterometrus swammerdamifrom India and Sri Lanka and Pandinus imperator,which can reach lengths between 15 and 20 cm. Thepentagonal sternum is the prominent feature of thisfamily with powerful, broad pedipalps. Most species inthis family are considered to be relatively harmless, buta few serious cases involving the genus Nebo in theMiddle East have been reported.

Nebo hierichonticusThis is the largest scorpion species in Saudi Arabiawhich can grow up to 11.3 cm. It is dark brown in color,prosoma is smooth, and pedipalps are thick and long. Itconstructs its own burrows and could be found underrocks and between crevices.

It is nocturnal, found mainly in margins of deserts orvery arid places across most of the Middle-Easterncountries. This species is widely distributed in the Al-Baha, Aseer, Attaif, Jazan, Al-Medina, Najran andTabuk regions of Saudi Arabia.

The venom of this species mainly consists of neuro-toxins, procoagulants, haemorrhagins, cardiotoxins,and necrotoxins. Effects of envenoming (sting) usuallyinclude immediate severe local pain, redness and swel-ling, local tissue injury and minor necrosis. Systemiceffects may include myocarditis. Nebo hierichonticushas been shown to cause mortality26, 27. Its sting leadsto untoward complications, intracranial haemorrhagesand death26, 27, 28, 29, 30, 31.

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Leiurus quinquestriatus.

Nebo hierichonticus.


HEMISCORPIIDAE

This family has previously been known as Ischnuridae,and Liochelidae32. Soleglad et al33 changed the nameto Hemiscorpiidae, and included the genusHeteroscorpion in addition to all genera and speciespreviously included in Liochelidae. This family consistsof 12 genera and 94 species, and inhabits the tropicaland sub tropical regions of all the continents exceptNorth America. The family’s center of distributionappears to be Africa where several genera are found,although it is also found in the Middle East. A typicalcharacteristic of many members of this family, espe-cially, Hadogenes, is that the scorpions are very flat(looks like somebody has stomped on them). This is anadaption to a life in cracks and crevices. Some long-living species can reach a length of more than 20 cm.Hemiscorpius lepturus is a very dangerous species ofserious medical significance found in the Middle East28,

29, 31, 34.Hemiscorpus lepturusThis is a small to medium-sized scorpion, adults areusually 5 -8.5 cm long, with very flat-looking body(dorso ventrally thin). It is usually yellow or pale yellow-brown in color with a dark dorsal median longitudinalstripe on cephalothorax and preabdomen. The postabdomen (and each of its individual segments) is verylong and thin (longer than the rest of the body combi-ned), and is more pronounced in males than females.Pincers are thick at base. Carapace is yellow to paleorange with eyes surrounded with black pigment.Tergites are pale yellow and the metasomal segmentsare yellow to pale orange. Telson vesicle is yellow.Aculeus is yellowish brown. Pedipalps are yellow withkeels marked with darker orange pigment and fingersare orange to reddish. Ventral surface, tergites and legsare also yellow. Chelicerae are also pale yellow withdarker orange teeth28, 29, 31.

It is mainly nocturnal in habit and usually hides itsdorso ventrally very flat body in very thin crevices orunder objects. These scorpions are most commonly

reported from hot and humid sites (like near certainrivers or permanent oases) in the Middle East andSouthwestern Asia, and in Saudi Arabia it has beenreported from the Riyadh region.

The venom has very potent cytotoxic effects but alsohas neurotoxic, cardiotoxic, and hemotoxic factors.Stings from this species causes progressive spreading ofsurface tissue necrosis, often looks like third degreeburned areas and takes a long time to heal; Systemiceffects include malaise, shock, hemolysis and secondaryrenal failure and sometimes leads to death28, 29, 31, 34.

CHARACTERISTICS OF SCORPION VENOMAND ASSOCIATED PHARMACODYNAMICS

The venom is produced by columnar cells of the venomglands located on the tail lateral to the tip of the stin-ger. The scorpion venoms are a complex mixture ofheterogeneous biologically active substances; includingvarying concentrations of histamine, serotonin, trypto-phan, hyaluronidases, phosphodiesterases, phopholi-pases, glycosaminoglycans, and cytokine releasers10, 35,

36. The scorpion venom also contains long chain andshort chain polypeptides. These three dimensionalpolypeptides exert their pharmacological effect due tobinding with specific receptors associated with ionchannels (in particular those for sodium, potassium,chlorine and calcium); leading to complex and rapidlyprogressive symptoms37, 38. These polypeptides are res-ponsible for causing impairment in nerves, muscles,and the heart function by altering sodium and potas-sium channel permeability. The long chain polypeptideneurotoxins may induce continuous, prolonged, repeti-tive firing of somatic, sympathetic and parasympathe-tic neurons which result in autonomic and neuromus-cular over excitation symptoms, besides altering nerveimpulse transmission. Some of these peptides alter torelease of neurotransmitters such as epinephrine, norepinephrine, acetylcholine, glutamate and aspartate.On the other hand the short polypeptide neurotoxinshave been shown to block the potassium channels39.

FACTORS AFFECTINGCLINICAL MANIFESTATIONS

Normally between 0.1 to 0.6mg of venom is injected bya scorpion sting10. The heterogeneity of the venomcomposition explains the variable response to venom asobserved in victims. The severity and clinical manifesta-tions of envenomation depend on variable factorsconcerning the scorpion as well as its victim. Scorpionvariables include size, age, nutritional status of the scor-pion, healthiness of the scorpion’s stinging apparatus(telson), number of stings and quantity of venom injec-ted, depth of the sting penetration, and composition ofthe venom10. Directly after hibernation the scorpionvenom is more concentrated. Moreover the response ofvenom is species dependent. Non-lethal scorpion spe-cies tend to produce local reactions while lethal scor-pion species tend to produce systemic symptoms40. Onthe other hand age, sex, weight and health status of the


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Hemiscorpus lepturus.


victim also determines the overall response to the sting. Itis because of these reasons children and elderly people areworst affected by sting. The underlying medical conditionof the patient such as hemophilia, concurrent anticoagu-lant therapy, diabetes mellitus, and cardiovascular diseasesall predispose to more serious response to envenoma-tion41. The site of the sting is also an important factorinfluencing the rapidity and severity of symptomatology.Stings in the head and neck are dangerous compared tothose on limbs. Closer proximity of the sting to the headresults in quicker venom absorption into the central circu-lation and a quicker onset of symptoms, while those onthe upper extremity are more serious compared to thoseon lower ones41. Envenomation usually occurs in subcuta-neous tissues, and less commonly in the muscle, whileinjection of the venom directly into a blood vessel is rare,but if it occurs, it may be catastrophic42.

Females are more susceptible than males to the sameamount of scorpion venom because of their lower bodyweight. No racial predilection exists. Any differences inindividual reactions to the scorpion sting are a reflection ofthat individual’s genetic composition rather than race43.

In general, the onset of symptomatology may vary bet-ween 5 minutes to 4 hours post envenomation, dependingon the site and depth of sting and if accidental injection ofthe venom into blood vessel has occurred, in which casevery rapid progression occurs41.

The response to scorpion envenomation is generally classi-fied as local and systemic responses.

LOCAL MANIFESTATIONS

Local evidence of a sting may be minimal or absent in asmany as 50% of cases of scorpion stings. A sharp burningpain sensation at the sting site, followed by pruritus, ery-thema, local tissue swelling, and ascending hyperesthesia,may be reported44. This paresthesia feels like an electriccurrent, persists for several weeks, and is the last symptomto resolve before the victim recovers9. The tap test is admi-nistered by tapping at the sting site. A positive result iswhen the paresthesia worsens with the tapping becausethe site is hypersensitive to touch and temperature. Infact, wearing clothing over the area and sudden changesin temperature exacerbate the symptoms43.

A macule or papule appears initially at the sting site, occur-ring within the first hour of the sting. The diameter of thelesion is dependent on the quantity of venom injected. Thelesion may progress to a purpuric plaque that will necroseand ulcerate. Lymphangitis may result from the transfer ofthe venom through the lymphatic vessels45. Pain, ery-thema, induration, and wheal are secondary to venomactivation of kinins and slow-releasing substances45.

SYSTEMIC MANIFESTATIONS

The major causes of the morbidity and mortality due tomedically important scorpion result from systemic toxi-city46. The different systemic manifestations observedin scorpion sting cases include the following:

Neurologic ManifestationsMost of the symptoms are due to either the release ofcatecholamines from the adrenal glands (sympatheticnerves) or the release of acetylcholine from postganglio-nic parasympathetic neurons18. Dual manifestations ofthe adrenergic and cholinergic signs are possible becauseof varying organ system sensitivities to these neurotrans-mitters47. Neurologic manifestations can be divided intocentral, autonomic, and peripheral effects.

Central Nervous System EffectsIn extreme cases of scorpion stings thalamus-inducedsystemic paresthesia usually occurs in all 4 limbs.Patients experience venom-induced cerebral thrombo-tic strokes. The level of consciousness is altered, espe-cially with restlessness, confusion, or delirium. Ataxia isalso a sign of the central nervous system effects of scor-pion sting. Classic rotatory eye movement may result innystagmus and blurred vision, Mydriasis or miosis mayalso occur. Patients may also have tongue fasciculation.Dysphagia, dysarthria, and stridor may occur secondaryto pharyngeal reflex loss or muscle spasm with exces-sive salivation and drooling47, 48, 49.

Autonomic Nervous System EffectsThe sympathetic manifestation of scorpion sting mayinclude trunkal hyperthermia with cold extremities,tachycardia, hypertension and arrhythmia, tachypnea,and hyperkinetic pulmonary edema. Other sympatheticmanifestations such as hyperglycemia, diaphoresis, res-tlessness, apprehension, hyper excitability, convulsionsand piloerection are also observed in some cases ofscorpion stings11, 46, 50, 51, 52.

The parasympathetic manifestations following scor-pion sting may include bronchoconstriction, bradycar-dia, hypotension, salivation, lacrimation, urination,diarrhea, emesis, rhinorrhea, bronchorrhea, goose pim-ple skin, loss of bowel and bladder control and genera-lized weakness11, 46, 50, 51, 52.

Peripheral nervous systemThe involvement of the peripheral nervous system inscorpion sting patient is manifested by intense localburning pain with minimal swelling at sting site, follo-wed by ascending numbness and tingling, paralysis andconvulsions may occur. Rigid spastic muscle of thelimbs, involuntary muscle spasm, twitching, clonus andcontractures, alternating episthotonus and opisthoto-nus are also seen as manifestations of scorpion stings.Increased tendon reflexes, especially prolongation ofthe relaxation phase have also been reported53.

Cardiovascular manifestationSevere envenomation by scorpion stings may result incardiovascular manifestations52, 54. It usually follows apattern of hyper dynamic phase followed by a hypodynamic phase. Hypertension is secondary to catecho-lamine and renin stimulation. It may be observed asearly as within 4 minutes after the sting and usuallylasts a few hours. Sometimes blood pressure is highenough to produce hypertensive encephalopathy.

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Hypotension is less common and occurs secondary toexcess acetylcholine or catecholamine depletion inpatients with parasympathetic manifestation49. Bothtachycardia and bradycardia have been reported due toscorpion stings46, 52. Cardiovascular collapse may occursecondary to biventricular dysfunction and profuse lossof fluids from sweating, vomiting, diarrhea, and hypersalivation. Cardiac dysfunctions may be attributed tocatecholamine induced increases in myocardial oxygendemand leading to myocardial ischemia and to thedirect effects of the toxin leading to myocarditis46.

Respiratory manifestationRespiratory failure may occur secondary to diaphragmaticparalysis, alveolar hypoventilation, and bronchorrhea55.This is secondary to a direct toxin induced increased pul-monary vessel permeability effect and is also secondary tocatecholamine-induced effects of hypoxia and intracellularcalcium accumulation, which leads to a decrease in leftventricular compliance with resultant ventricular dilationand diastolic dysfunction55.

Gastrointestinal manifestationsPatients may present with excessive salivation, nausea andvomiting. Occasionally dysphagia may be observed. Gastrichyper-distention may occur secondary to vagal stimula-tion. Increased gastric acid output may lead to gastriculcers. Rarely acute pancreatitis may occur. Liver glyco-genolysis may occur from catecholamine stimulation56, 57.

Genitourinary manifestationsToxin-induced acute tubular necrosis renal failure mayoccur. Rhabdomyolysis renal failure may result fromvenom induced excessive motor activity. Priapism mayoccur secondary to cholinergic stimulation58. Bawaskar59

reported a positive prognostic correlation to the deve-lopment of cardiac manifestations following scorpionstings if priapism occurs.

Hematological manifestationsPlatelet aggregation may occur because of catechola-mine stimulation. Disseminated intravascular coagula-tion with massive hemorrhage may result from venom-induced defibrination27, 47, 60.

Metabolic manifestationsHyperglycemia may occur from catecholamine inducedhepatic glycogenolysis, pancreatitis, and insulin inhibi-tion. Lactic acidosis may occur from hypoxia and venominduced increased lactate hydrogenase activity.Patients may have an electrolyte imbalance and dehy-dration from hyper salivation, vomiting, diaphoresis,and diarrhea11, 46, 51, 52, 61.

Diagnoses of Scorpion EnvenomationIn a patient who presents with a history of bite/sting byan unknown animal, a constellation of detailed historyis needed to clarify the prominent symptoms besidesthorough clinical examination to identify the cardinalsigns and some laboratory investigations may point tothe offending animal and perhaps its species62. Themost notable aspect of a scorpion sting is significant

pain at the puncture site that increases markedly withtapping lightly but with minimal noticeable local red-ness or edema63.

Base line laboratory studies such as serum electrolytes,blood urea nitrogen (BUN), random blood sugar, andserum creatinine levels should be analyzed in cases ofsuspected envenomation64. Cardiac enzymes such ascreatine phosphokinase (CPK), and its iso-enzyme (CK-MB), and lactated dehydrogenase (LDH) should bemonitored in cases of myocardial toxicity65.

A protocol of investigation in cases with significantenvenomation is given below:

Laboratory StudiesBlood count for leukocytosis and hemolysis is to beundertaken in patients with stings from theHemiscorpius species. Electrolyte evaluation is warran-ted in patients with venom induced salivation, vomiting,and diarrhea. Coagulation parameters should be measu-red for venom induced defibrination because, at highconcentrations, the venom acts as an anticoagulant.

ElectrocardiogramElectrocardiography is an important investigationwhich helps in diagnosis of fatal conduction distur-bance, ischemia and very importantly myocarditis incases of severe envenomation. ECG changes may persistfor 10-12 days before normalizing9, 47, 66.

Arterial blood gas determinationsA decrease in arterial oxygenation tension and anincrease in PCO2 within 15 minutes are also seen in casesof severe scorpion envenomation, presence of thesesymptoms is an indication of mild metabolic acidosis67.

MANAGEMENT OF SCORPIONENVENOMATION

There are no uniform guidelines for the treatment ofscorpion sting patients. Overall scorpion sting treat-ment falls into two categorization, the pre hospitaltreatment or the first aid, and the in hospital treatmentfor severe envenomation cases68.

The Pre-hospital Treatment/First Aid MeasuresThe first aid and pre-hospital treatment of scorpionstung patients is an important determinant of the mor-bidity and mortality resulting from scorpion stingbecause it may delay the systematic absorption of thevenom, and consequently delay the morbidity, On theother hand, if inappropriate first aid is given for exam-ple employment of traditional remedies may worsenthe condition69.

The most accepted protocol of first aid for suspected orproven scorpion stung patients is firstly reassurance ofthe patient followed by immediate use of the pressure-immobilization bandage which aims to retard venomtransport via the lymphatic system9. This is achieved ina dual approach. First, by applying a bandage to compress


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the lymphatic vessels at the sting site, second, splintingthe limb so that proximal movement of lymph in the ves-sels is slowed or stopped by splinting the limb as a frac-tured one thus stopping also the muscle pump effect ofmuscle movement. This technique can virtually stopvenom movement into the circulation without anythreat to limb oxygenation, which is one of the majorproblems in using tourniquet70, 71.

Pharmacotherapy at HospitalThe goals of pharmacotherapy are to reduce morbidity,to prevent complications, and to neutralize the toxin72, 73.It is advocated that the definitive treatment should takeplace within a critical care area of the hospital, such asintensive care unit or emergency department, wherecomplications arising from envenomation or reactions toantivenom can be best managed74.

Supportive care is probably of more benefit than antive-nom75. When the patient has been transported to thehospital, the key is to watch for signs of severe enveno-mation and to blunt their effects before more damage isdone63. In cases of systemic manifestations it is importantthat vital signs (e.g., pulse oximetry, heart rate, bloodpressure, and respiratory rate monitor) are closely moni-tored. Oxygen is to be administered along with intrave-nous fluids to prevent hypovolemia from vomiting, diar-rhea, sweating, hyper salivation, and insensible water lossfrom a tropical environment. In cases where respiratorydistress is observed, intubation and administration ofmechanical ventilation is strongly recommended withregular end-tidal carbon dioxide monitoring73. For hyperdynamic cardiovascular changes, administration of a com-bination of beta-blockers with sympathetic alpha-blockersare most effective11, 52. Use of beta-blockers alone is to beavoided since it may lead to an unopposed alpha-adre-nergic effect. Also, nitrates can be used for hypertensionand myocardial ischemia72.

Alpha receptor stimulation plays an important role in thepathogenesis of pulmonary edema. Prazosin by blockingthe alpha-1 adrenergic receptors may decrease the peri-pheral resistance without having any effect on the cardiacrate and decreases the tension via vasodilatation. In addi-tion, prazosin provides a resolution of the patient’s clini-cal symptoms by reverting inotropic (hypertension) andhypokinetic (pulmonary edema, tachycardia and hypoten-sion) phases following alpha adrenergic receptor stimula-tion caused by scorpion venom76. Patients whose pulmo-nary edema continues or recurs should be given prazosin(250 – 500 µg) every 3 hours until their clinical symptomsdisappear48, 52. The time between the sting and adminis-tration of the first dose of prazosin for symptoms of pul-monary edema probably determines the outcome77, 78. InSaudi Arabia, the majority of scorpion sting envenoma-tion fortunately follows a benign course and can be safelytreated with supportive measures alone without the useof antivenom79. Oral prazosin is fast acting, easily availa-ble, relatively cheap, free from any anaphylaxis, andhighly effective in scorpion sting envenomation52.

For hypodynamic cardiac changes, a titrated monitoredfluid infusion with after load reduction helps to reduce

mortality. A diuretic may be used for pulmonary edemain the absence of hypovolemia, but an after load redu-cer, such as prazosin, nitroprusside is better. Inotropicmedications, such as digitalis, have little effect, whiledopamine aggravates the myocardial damage throughcatecholamine like actions. Dobutamine seems to be abetter choice for the inotropic effect. Finally, a pressorsuch as norepinephrine can be used as a last resort tocorrect hypotension refractory to fluid therapy73. If thepatient has not developed any symptoms or signs ofenvenomation, close observation of the patient for aperiod of 8 hour is advised, during this period an hourlycheck of the patient should be performed to assess thelevel of consciousness, pulse rate and rhythm, bloodpressure, respiratory rate and any new symptoms orsigns11, 46, 51, 52, 80.

THE ANTIVENOM THERAPY

Anti venom is considered as an effective means formanaging scorpion envenomation. The general indica-tion of antivenom therapy is when the patient hassigns and symptoms suggestive of severe or progressivelocal and/or systemic manifestations of envenoma-tion81. Systemic envenomation is suggested if there is acardiovascular manifestation such as shock, abnormalECG, cardiac arrhythmias, heart failure or pulmonaryedema. Moreover, impaired conscious level of anycause is a clue to systemic envenomation49.

The intravenous administration of antivenom is consi-dered to be the effective route. For intravenous infu-sion, dilution of the antivenom1 in 5 or 1 in 10 in phy-siological saline helps to reduce the incidence of reac-tions and gives better control over the rate of adminis-tration. For the cases with history of allergy, furtherdilution with 1: 100 or 1: 1000 is required. Slow intra-venous injection of undiluted antivenom at a rate notexceeding 2ml per minute although successful carriesthe risk of development of rapid uncontrollable, poten-tially serious reactions, and it is unpractical when largevolumes have to be injected82.

If response to initial antivenom dose is not satisfactory,use of additional doses is advocated. However, there isno study establishing an upper limit of dose. Infusionmay be discontinued when satisfactory clinical impro-vement occurs even if recommended dose has not beencompleted83. However in patients with an atopic his-tory (asthma, hay fever, vernal conjunctivitis, eczemaand food and drug allergies) and those who have hadreactions to equine antiserum on previous occasionshave an increased risk of severe reactions, pre-treat-ment with corticosteroids may prevent or diminishthese reactions. Rapid desensitization is not recom-mended80, 84. When the risk of anaphylaxis is very high,a 10 milliliter ampoule of 1 in 1000 epinephrine may beplaced in a second intravenous bottle and the dosetitrated to control symptoms80, 84.

On the other hand, treatment of scorpion sting by antive-nom is still facing some difficulties due to absence of stan-dardized protocol of management regarding grading of

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the case and the proper dosing schedule of antivenomused in each grade. Unfortunately the most widely usedprotocol in many developing countries is incorrect68 andusually involves the use of one ampoule per each scor-pion stung victim, this non scientific practice is usuallyattributed to, the fear of early or late intolerance reac-tion to antivenom, the limited availability of antive-nom especially in rural and desert areas, the cost of theproduct, and the ignorance of medical practitionersconcerning the method of administration and efficacyof antivenom and finally the ignorance in pathogene-sis, and symptoms of scorpion stings and to variabilityon presentation according to scorpion species involved.This leads to the antivenom usually being given in anarbitrary dose68.

Antivenom therapy should not be used routinely andindiscriminately because available commercial antive-nom carries a risk of potentially serious serum reac-tions. Moreover antivenom is not always necessary asmany patients stung by venomous scorpions are notenvenomed (dry sting) and additionally antivenoms areexpensive, always in short supply and has a limitedshelf life85. Recent studies also discourage the use ofantivenoms and suggest that scorpion envenomationcan be better managed by supportive care and the-rapy52, 86, 87. Antivenom appears to be species specificand needs to be administered within 1 hour of enve-nomation88, which limits it use to regions that have aknown single species and access to a local health sta-tion where the appropriate antivenom can be stored,which seems to be an effective policy in some parts89.Moreover scorpion toxins are not good antigensbecause of their small size and poor immunogenicity.They do not induce antibodies that cross react againsttoxins of other scorpion species unless a 95% aminoacid sequence homology exists between the 2 toxins.Thus, no universal antivenom is available. Furthermore,the neurotoxin component of the scorpion venomtends to be the least immunogenic, resulting in the lowefficiency for neurological complications76.

ADVERSE REACTIONS ASSOCIATEDWITH ANTIVENOM THERAPY

Early (Anaphylactoid) reactions

These develop within 10-180 min of starting antivenomin 3-54% of patients. Incidence increases with dose anddecreases with highly refined preparations or intra-muscular injection (which is useless). The symptomsinclude itching, urticaria, cough, nausea, vomiting,other autonomic manifestations, fever, and tachycar-dia90. Up to 40% of patients showing early reactions,develop systemic anaphylaxis (hypotension, bronchos-pasm and angioneurotic oedema). The early reactionsare probably due to complement activation. They aretreated by adrenaline, antihistamine, hydrocortisone,water sponging, and antipyretics in case of fever84.

Late (Delayed) reactions

Serum sickness type reactions may develop within 5-24(mean 7) days after antivenom administration. The rate

and speed of development increase with antivenomdose. The symptoms include fever, itching, urticaria,arthralgia, lymphadenopathy, periarticular swelling,albuminuria, and rarely encephalopathy. They respondto oral prednisolone (5 mg q 6 h for 5-7 days).

Contraindications for antivenom

This includes atopic patients and those with a history ofsensitivity to equine antiserum. Antivenom, however,should be given in cases of severe systemic enveno-ming. Reactions may be prevented or ameliorated bypretreatment with adrenaline, antihistamines, andhydrocortisone.

Education and Prevention of Scorpion sting

Occupational risk for scorpion sting is noticed fre-quently among soldiers involved in preparing areas formaking trenches, and while handling materials, wood,etc. in the field and/or resting near areas where scor-pions hide. The soldiers are to be instructed to checkshoes, gloves, clothing and package before use and toavoid walking barefoot especially at nights. Othersafety precaution includes avoid playing with scorpionsas past time during camp duties. Prevention of scorpionstings can be challenging, not because the interven-tions themselves are difficult but because military per-sonnel usually fail to observe these basic rules.

SUMMARY

Scorpion sting was the most frequent cause of enveno-mation among the troops stationed in Saudi Arabiaduring the recent Arab – Gulf War. The scorpions res-ponsible for these stings belong to the family Buthidae,Scorpionidae, and Hemiscorpiidae. A typical manifesta-tion of scorpion sting may be characterized by severeexcruciating pain with marginal erythema, edema,inflammation, hypotension, salivation, priapism, tachy-cardia, hypertension, perspiration, nausea, headacheand muscle cramps. Severe envenomation may result incytotoxicity, neurotoxicity, respiratory and cardiovascu-lar toxicity which may be life threatening. The majorityof patients can be treated with analgesic, local applica-tion of ice along with symptomatic treatment. The useof antivenom is restricted to serious cases with systemicmanifestations. Identification of scorpion might help intreatment strategies. Preventive measures includingemptying boots before putting them on, inspection ofclothing before dressing and keep sleeping bags tightlyrolled might avoid scorpion stings.

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42. DAVIDSON TM. Intravenous rattle-snake envenomation.Am J Med 1988; 148: 45-47.

43. RADMANESH M. Androctonus crassicauda sting and its cli-nical study in lran. J Trop Med Hyg 1990; 93 (5): 323-6.

44. MAHADEVAN S. Scorpion sting. Indian Pediatrics 2000; 37:504-514.

45. RADMANESH M. Cutaneous manifestations of theHemiscorpius lepturus sting: a clinical study. Int JDermatol 1998; 37 (7): 500-7.

46. GAJRE G, DAMMAS AS. Scorpion envenomation in chil-dren: should all stings be given antivenom? Annals ofSaudi Medicine 1999; 19 (5): 444-446.

47. ISMAIL M. The scorpion envenoming syndrome. Toxicon1995; 33 (7): 825-58.

48. BAWASKAR HS, BAWASKAR PH. Scorpion sting: Update.JAPI 2012; 60: 46-54.

49. DAS S, MINI P, ANANTHAKRISHNAN S. Cardiac involve-ment and scorpion envenomation in children. J TropPediatr 1995; 41 (6): 338-40.

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53. GHALIM N, EL-HAFNY B, SEBTI F. Scorpion envenomationand serotherapy in Morocco. Am J Trop Med Hyg 2000; 62(2): 277-83.

54. SOOMRO RM, ANDY JJ, KONTRACTOR S, EL-HADY AM,EORES OA, PARVATHAREDDY S, GANNI K, AHMED N.Cardiovascular complication of scorpion stings and effectsof antivenom. J Saudi Heart Assoc 1998; 10 (1): 2-10.

55. AMARAL CFS, DE-REZENDE NV, FREIRE-MAIA-L. Acute pul-monary edema after Tityus Serrulatus scorpion in children.Am J Cardiol 1993; 71: 242-45.

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57. CHOI DW. Calcium: still center-stage in hypoxic-ischemicneuronal death. Trends Neurosci 1995; 18: 58-60.

58. NAQVI R, AKTHAR F, RIZVI A. Acute renal failure develo-ping after a scorpion sting. Br J Urol 1998; 82 (2): 295.

59. BAWASKAR HS. Diagnostic cardiac Premonitory signs andsymptoms of red scorpion sting. Lancet 1982; 2: 552-54.

60. DEVI CS, REDDY CN, DEVI SL. Defibrination syndrome due toscorpion venom poisoning. Br Med J 1970; 1 (692): 345-7.

61. GOYFFON M, VACHON M, BROGLIO N. Epidemiologicaland clinicalcharacteristics of the scorpion envenomationin Tunisia. Toxicon 1982; 20 (1): 337-44.

62. BARBERA J. Investigation and technical of snake bite.Toxicon 1998; 36 (3): 431-446.

63. SAUCIER JR. Arachnid envenomation. Emer Med Clin NAm 2004; 22: 405-422.

64. GOLD BS, BARISH RA. Venomous snake bites. Currentconcepts in diagnosis treatment and management. EmergMed Clin North Am 1992; 10 (2): 249-67.

65. CHIPPAUX JP, WILLIAMS V, WHITE J. Snake venom variabi-lity methods of study, results and interpretation. ToxiconNoll 1991; 1279-1303.

66. HERING SE, JURCA M, VICHI FL, MARISA M, MARQUES A,CUPO P. Reversible cardiomyopathy in patients withsevere scorpion envenomation by Tityusserrulatus.Evaluation of enzymatic, electrocardiographic, echocar-diographic alterations. Am Trop Pediatr 1993; 13: 173-182.

67. AMARAL CF, LOPES JA, MAGALHAES RA, DE REZENDE NA.Electro cardiographic, enzymatic, and echocardiographicevidence of myocardial damage after Tityus serrulatusscorpion poisoning. Am J Cardiol 1991; 67 (7): 655-7.

68. BEN ABRAHAM R, WINKLER E, ESHEL G, BARZILY Z, PARET G.Snake bite poisoning in children, a call for unified clinicalguidelines. Eur J Emerg Med 2001; 8 (3); 189-92.

69. NEWMAN WJ, MORAN NF, THEAKSTON RDG, WERRELLDA. Traditional treatment for snake bite in a rural Africancommunity. Anus Trop Med Parasit 1997; 91 (8): 967-69.

70. HOWARTH DM, SOUTHEE AE, WHYTE IM. Lymphatic flowrates and first aid in simulated peripheral snake or spiderenvenomation, Med J Aust 1994; 161: 695-700.

71. JUCKETT G, HANCOX JC. Venomous snake bites in theUnited States: management review and update. Am FarmPhysician 2002; 65 (7): 1367-74.

72. HAVIV J, HUERTA M, SHIPILBERG O, MIMOUNI D, ASL N,GROTTO I. Field treatment of snake bites in the IsraelDefense forces. Public Health Rev 1998; 26 (3): 247-56.

73. FREIRE-MAIA L, CAMPOS JA, AMARAL CF. Approaches tothe treatment of scorpion envenoming. Toxicon 1994; 32(9): 1009-14.

74. CARELS RA, JANSE M, KLAVER PS, DEVARIES J, KAGER PA.Acute management of patients bitten by poisonous


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75. GIBLY R, WILLIAMS M, WALTER FG. Continuous intravenousmidazolam infusion for Centruroides exilicauda scorpionenvenomation. Am Emerg Med 1999; 34 (5): 620-5.

76. ABROUG F, AYARI M, NOURIA S, et al. Assessment of leftventricular function in severe scorpion envenomation:combined hemodynamic and echo-doppler study.Intensive Care Medicine 1995; 21: 629-35.

77. BAWASKAR HS, BAWAKAR PH. Prazosin therapy and scorpionenvenoming. J Assoc Physician India 2000; 48: 1175-80.

78. ADHISIVAM B. Prazosin and purses. Lancet 2006; 368:1870.

79. DITTRICH K, AHMED R, AHMED Q. Cardiac arrest follo-wing scorpion envenomation. Ann Saudi Med 2002; 22:87-90.

80. TIBBALLS J. Premedication for snake antivenom. Med JAust 1994; 160: 4-7.

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82. WIN-AUNG, TIN-TUN, KHIN-MAUNG, et al. Clinical trial ofintramuscular anti-snake venom administration as a firstaid measure in the field in the management of Russell’sviper bite patients. Southeast Asian J Trop Med PublicHealth 1996; 27 (3): 494-7.

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for diagnosis and monitoring for hemorrhagic syndromeafter viper envenomation in sub-Saharan, Africa MedTrop 1998; 58 (4): 369-71.

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85. SMITH TA, FIGGE HL. Treatment of snakebite poisoning.Am J Hosp Pharm 1991; 48: 2190-6.

86. ALPAY NR, SATAR S, SEBE A, DEMIR M, TOPAL M. Unusualpresentations of scorpion envenomation. Hum Exp Toxicol2008; 27: 81-85.

87. PEKER E, OKTAR S, DOGAN M, KAYA E, DURU M. Prazosintreatment in the management of scorpion envenomation.Hum Exp Toxicol 2010; 29 (3): 231-233.

88. MAZZEI DE DAVILA CA, DAVILA DF, DONIS JH, DE BELLA-BARBA GA, VILLARREAL V, BARBOZA JS. Sympathetic ner-vous activation, antivenin administration and cardiovas-cular manifestations of scorpion envenomation. Toxicon2002; 40: 1339-46.

89. OSNAYA-ROMERO N, DE JESUS MEDINA-HERNANDEZ T,FLORES-HERNANTEZ SS, LEON ROJAS G. Clinical symptomsobserved in children envenomed by scorpion stings, at thechildren’s hospital from the state of Morelos, Mexico.Toxicon 2001; 39(6): 781-5.

90. CHEM J, BULLARD MJ, CHIU TE, NG CJ. Risk of immediateeffects from F2 bivalent antivenin in Taiwan. Wilderness-Environ Med 2000; 11(3): 163-7.

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cutanplast_190x65.pdf 1 30/10/12 17:38

By A. AGAL❶, M. JAAFAR❶, C. BACCARI❶ and S. HADDAD❶. Tunisia

Ammar AGAL

The Role of Tunisian Military Veterinarians ina Refugee Camp Close to the Libyan Border.*

Vétérinaire commandant AGAL Ammar.Diplôme : Docteur en Médecine Vétérinaire.

Formation : Epidémiologie appliquée à la lutte contre les maladies infectieusesanimales.

Carrière :- 1991: Incorporation au sein du corps des médecins vétérinaires de l’armée Tunisienne.- 1992-2002 : Assistance sanitaire des camélidés; contrôle de l’hygiène alimentaire et la qualité de l’eau desBrigades sahariennes.- 2002 : Assistance sanitaire des cynophiles, contrôle de l’hygiène alimentaire et de la qualité de l’eau desgarnisons du Nord-Ouest.- 2007 : Assistance sanitaire des cynophiles, contrôle de l’hygiène alimentaire et de la qualité de l’eau dela garnison de Bizerte.


ARTIC

LES

ARTIC

LES

RESUME

Le rôle des vétérinaires militaires tunisiens dans un camp de réfugiés près de la frontière libyenne.

Le 20 février 2011 la frontière tuniso-libyenne a été envahie par des dizaines de milliers de réfugiés.L’armée tunisienne a été chargée d’installer en urgence un camp de réfugiés dont les objectifs fondamentaux sont d’une part,la préservation de la santé de ces personnes déplacées, c’est-à-dire leur bien-être, physique, moral et social. D’autre part leurfournir un logement adéquat, de l’eau potable, de la nourriture et un environnement sain.La mission des vétérinaires militaires était de participer à la gestion du camp et de coordonner l’action des ONG et des agencesde l’ONU en vue de :

• Prévenir les toxi-infections alimentaires collectives,• Prévenir la dissémination des maladies à transmission hydrique,• Promouvoir l’hygiène,• Gérer les déchets selon la législation tunisienne,• Lutter contre les vecteurs.

La conception d’un camp de réfugiés demande un effort multidisciplinaire basé sur un esprit de coopération entre tous les intervenants.Pour les vétérinaires militaires tunisiens ce fut une expérience unique et exceptionnelle où ils ont confirmé leur capacité à maîtriserles risques en relation avec la santé publique vétérinaire malgré les difficultés rencontrées.

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KEYWORDS: Refugee Camp, Choucha, Sphere project, NGOs, UNICEF.MOTS-CLÉS : Camp de réfugiés, Choucha, Projet sphère, ONG, UNICEF.

In February 2011, anti-government protests erupted inLibya and quickly turned violent. The conflict grew andcaused a mass exodus to neighboring countries, espe-cially Tunisia. During just the first two weeks of theconflict more than 91,854 refugees have crossed theTunisian-Libyan border. The majority of the refugeeswere composed of young men and middle-aged,foreign manual workers. Tunisia has never beenconfronted by such an influx of refugees.

Despite economic difficulties, political instability, inse-curity, uncertainty about the duration of the conflict in

Libya and the lack of national strategies to manage amassive influx of immigrants. The Tunisian Army wasgiven the enormous task to prepare an emergency fieldhospital, and install a suitable camp as quickly as possible.

Before the Libyan conflict, the only thing we knew was

❶ Service de Médecine VétérinaireDirection Générale de la Santé Militaire, Bab SaadounTN - 1002 Tunis (Tunisie);

* Presented at the 3rd ICMM Maghrebian Congress on Military Medicine,Nouakchott, Mauritania, 17-21 April 2013.

Veterinaire tunisien_AGAL_Mise en page 1 21/03/14 11:40 Page1

the number of foreign workers in Libya, estimated bet-ween 1.5 and 2.5 million, with a significant proportionof families for a Libyan population of around 6.4 mil-lion persons composed of mostly young people.

The camp was located in the region of Choucha, 9 kmfrom the Tunisian-Libyan border and 20 km from thenearest town, on an area of 17 ha. This region was cho-sen as a camp site because it offered the followingamenities: an open field, sandy soil with quick waterdrainage, electricity connection, a network of freshwater, and two security posts (Police station and borderpatrol station). (Photo n°1)

The main objective of a refugee camp is the preservationof the health of the displaced. Physical, moral and socialwell-beings of the refugees must be cared for in additionto providing them with adequate shelter, medical care,clean water, food and a healthy environment4.

The above mentioned values, human needs and func-tions are among the fundamental roles of veterinarypublic health and hence veterinary presence is neededduring the installation and the subsequent operation inthe refugee camp1.

The camp has gone through three phases: a setupphase, a consolidation phase and a maintenance phasewith specific changes in each period. (Table.1), (Table.2)

It is worth noting that the population of the camp isbeing renewed in its majority every 3 or 4 days at therate of the arrivals and the departures5.

The mission of military veterinarians was to participatein camp management and to coordinate the work ofNGOs and UN agencies in order to:

PREVENT FOODBORNE ILLNESS

This prevention began by controlling the anarchic sup-ply and storage of food. Major supplies came fromdonations of Tunisian people especially on the week-ends, and were stored in open air. (Photo n°2)

After securing the food supply and storage, veterina-rians needed to inspect and correct the two types ofkitchens that were present at the camp:

* Kitchens run by NGOs whose working methods werecorrect. (Photo n°3)

* Chaotic kitchens run by volunteers who did not respectthe rules of hygiene in the preparation and distribution ofmeals.

Lastly, control of the operations in order to ensure adequatequality and quantity of food.

To solve these problems, many measures were takenand meetings with NGOs were organized in order toselect and organize food stocks.• A big tent "Rubs Hall" was reserved for food storage.• Different tents were used for cleaning products anddisinfectants (Photo n°1).• Area for cooking and food preparation.

We identified not only all parties involved in the foodsystem, but also all the adequate and certified kitchens


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Photo 1: General view of the camp (A big tent Rubs Hall).

SETUP PHASE

20-28 FEBRUARY 2011CONSOLIDATION PHASE

28 FEBRUARY - 12 MARCH

MAINTENANCE PHASE

FROM 13 MARCH

AREA 17 ha 17 ha

NUMBER OF REFUGEES 20000 17000 < 4000

NUMBER OF TENTS 63 3000 700

NUMBER OF KITCHENS 6 3 3

NUMBER OF DISTRIBUTION POINTS 7 3 3

NUMBER OF MEALS 40000 17000 4000

NUMBER OF WATER POINTS 40

SPECIFICATIONS

Full support bythe Tunisian population

Arrival of NGOsImprovement inservice deliveryHigh density of refugees,

anarchic arrangement of tents

Table 1: Evolution of the characteristics of the camp in three phrases2, 5.


and points of distribution. We have established standardmenus that reflect the culinary traditions of refugees:pasta for even days and rice for odd days. Poultry meat wasserved in all meals (daily supply, cut meats, ready to cook).We determined the meal times/schedule to be from 13:00to 17:00 in order to avoid waste (40,000 meals for 17,000refugees) and disorder. In fact some refugees were servedby two kitchens successively. We closed all kitchens whichwere run by volunteers because they were uncontrollable,and limited their functions to just the distribution of dryand prepackaged foods under veterinary supervision.

The inspection of these kitchens was the duty of mili-tary veterinarians and personnel of the ministry of

health who also carried laboratory tests of food suppliesand the catering tools.

The results of these inspections resulted in:• Seizure of 57,000 packets of High energy bars (expired).• Seizure of 600 kg of poultry for repulsive aspect(poor conditions of storage during transport/rotten).

Since the consolidation phase, each product must gothrough the military veterinary.

We have also encountered other health issues outsidethe camp kitchens such as those associated with mer-chants located along the road side were selling variousgoods such as rice, meats, drink, etc. There were evensheep slaughtered and sold in the camp without per-mission. (Photo n°4)

WATER HYGIENE

Access to safe water is a fundamental right for humans,particularly for refugees because of their vulnerablesituation4. At the beginning, the fresh water was ser-ved in bottles of mineral water from donations distri-buted primarily with meals. Later we established thedistribution of drinking water network and installedwater tanks (5 cubic meters equipped with 6 tapconnection) for drinking, showers and personalhygiene. (Photo n°5)


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CATEGORIES OF POPULATION SETUP PHASE CONSOLIDATION PHASE MAINTENANCE PHASE

Number of families

Women and families withchildren receive care in tentsthat are set apart and instal-

led by a private donor

165 577

Number of pregnant women - 21

Total number of children 70 577

0 to 3 years - 202

3 to 6 years - 108

6 to 12 years - 94

12 to 18 years - 173

Table 2: Profile of families in the different phases of the camp5.

Photo 2: Food stored in open air.

Photo 3: Kitchen runs by NGOs.Photo 4: Water tanks.


During the workshops, NGOs were given the task ofproviding tanks for drinking water. Then in the phaseof maintenance, we decided to drill a well to providewater to the whole camp. (Photo n°6)

The health control of the water consists in a globaltechnical expertise of the system of production (systemof reverse osmosis) and of distribution of the water(mobile tank and fixed tanks) which includes:

1. The periodic inspection of facilities;2. The control of measures implemented for sanitary

security;

3. The realization of a test program of the quality ofthe water.

We opted for the use of an approach of “projectable sim-plified laboratories”. We used a transportable suitcasefor the bacteriological analysis of water. (Photo n°8)

We used the technique of membrane filtration formicrobiological control of water in the Choucha Camp.

- Detection and enumeration of Enterococci: XP T 90-416,- Detection and enumeration of Escherichia coli andcoliform bacteria, EN ISO 9308-1,- Enumeration of viable microorganisms at 37° C and22° C: XP T90-401 T90-402 XP,- Detection and enumeration of the spores of sulfite-reducing anaerobes, NFT 90-415.

Samples were taken once a week for bacteriologicalanalysis. All these samples were satisfactory in terms ofbacteriological analysis.

For the chemical parameters, a spectrophotometer wasused; simple material to use thanks to the tests in tubesHACH-LANGE. The spectrophotometer was comple-mented by other tools: pH-meter, turbidity-meter,conductivity meter, and chlorimeter (dosage of thechlorine).

These analyses are made according to 03 establishedguides: (Table.3)

A daily control of the total chlorine and the free chlorine(0,1mg/l anywhere of networks distribution; 0, 3 mg/l intanks of storage).

The water of the drilling was treated by a system ofreverse osmosis because it presented a rate of 3gNaCl/liter of raw water. (Photo n°7)

Some of the chemical analysis of water was performedby the laboratory of the ministry of Public Health.

ENVIRONMENTAL HEALTH

The camp was filled by waste of all kinds: used sheets,blankets; household waste, cans, cardboard… (Photo n°9)

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Photo 5: Drilling for water supply camp.

Photo 6: Transportable suitcase for the analysis of water.

P1 P2 P3

ANALYSIS OF RESOURCE WATERS P1

ANALYSIS IN THE POINT OF PUTTING

TO DISTRIBUTION

Disinfection alone 2/year 1/month

1 / 7day

Microfiltrationor

Ultrafiltration2/year 4/year

Reverse .Oor

Distillation1/year 4/year

ANALYSIS IN THE POINT OF PUTTING IN

COSUMPTIONP3

Table 3: Analysis programs.


These conditions were the result of the following:• Lack of a garbage collection plan;• Non recognized and non complementing teams of

volunteers;• The use of paid volunteers by some NGOs for the

cleaning of their settlements.

After a series of meetings held with NGOs and therepresentatives of the municipality of Ben Guerdane onthe management of solid waste, proposals for the sub-contracting of the cleaning of the camp with a private

company was admitted, it enables:1. Collect the waste from identified collection points.

(Photo n°10)2. Take away the waste by trucks to large containers

and then to a landfill.

This resulted in a clear environmental improvement inthe camp which was getting better day after day.

SANITATION

The presence of an insufficient number of toilets in thecamp without water connection or drainage systems;the droppings around the camp and its surroundings;overload and long queues in front of the toilets espe-cially for women; uncontrolled use of toilets and accu-mulation of excreta, lead to the proliferation of fliesand unpleasant odors.

We have given instructions to the officials of BenGuerdane to urgently clean the toilets. We have also coor-dinated with UNICEF representatives to dispatch andconnect new toilets in sufficient numbers to comply withthe SPHERE standards (1 latrine/20 persons)4. We organi-zed awareness sessions for refugees for consolidation ofhealth education efforts and specific advertising cam-paigns, taking into account the multitude of origins ofthese refugees, with whom it is often difficult to commu-nicate in the languages most commonly used. (Photo n°10)The plan of the camp provides isolated and closed spacesfor families with locked toilets for women and theirbabies; the toilets were placed by sector around the campwith a distance from the tents of 20 to 50 meters4; weproposed a plan for cleaning and disinfection accordingto the different types of latrines. (Photo n°15)

The implementation of a plan of cleaning and disinfec-tion adapted to different types of latrines, with dailyapplication of quicklime at the level of pits. (Table.4)

VECTOR CONTROL

The resulting of stagnant water around kitchens andwater points presented major breeding grounds tomosquitoes. The poor organization of food storage hasincreased the risk of proliferation of rodents and flies.A private company was charged by ONG’s to ensure 3D


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Photo 7: Water treatment by reverse osmosis.

Photo 8: Waste of all kinds.

Photo 9: Waste collection point.

Photo 10: Panels sensitization and health education.


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Photo 12: Cabin toilets and showers.

Photo 13: Cleaning and disinfection of a chemical toilet.Photo 11: Toilet connected to septic system.

TYPE OF TOILET SPECIFICATIONS TREATMENT NUMBER

Pit latrines

Type A(Photo n°11)

The latrines areconnected to septic

concrete or PVCplastics which are

provided with a holefor emptying thesanitation truck.

83

Latrine block(Photo n°12)

38

Chemical toilets(Photo n°13)

Constituted bya cabin for isolation

of the user.Under the bowl is

installed a tank of 200liters of waters

to which is addeda disinfectant.

Periodically,the receptacle of

excremental materialtank must be drained.

23

Dry latrine (trench latrines)(Photo n°14)

5 trenches for 100men for 3 days

Twice daily monitoringwith a disinfection

solution of chlride oflime to 10%.

When the trench idhalf full, it is takenout of service, then

disinfected and filled.

488

Table 4: Distribution and number of different latrines in the Choucha Camp2.

Photo 14: The trench latrines.


operation (Désinfection - Disinsectization - Rodentcontrol). (Photo n°16)We had the task of technical and chemical operationscontrol.

The products used were the synthesis pyréthrinoïdes tofight against mosquitoes, flies and anticoagulantsagainst the rodents. All the products were authorizedby the Ministry of Public Health in Tunisia.

FIGHT AGAINST VENOMOUS PESTS

The camp site is a natural environment for scorpions(Androctonus australis), vipers (Cerastes cerastes) (Photon°17) and poisonous snakes (Naja-haje-legionis)3, 6.

We proposed education sessions for refugees and staffon:

• Risks in case of contact with venomous animals;• Identification and timing of their activities;• Knowing their habitat and conditions for their pro-

liferation;• Methods of prevention.

A general inspection of the camp was done every twodays, with the participation of:

1. Military veterinary;2. Representative of MSP, and;3. An NGO representative.

The report of this inspection was discussed with all stake-holders during the workshops.

CONCLUSION

The potentiality of armed forces enable to implement,skills and varied operational techniques, characterizedby the autonomy, the endurance, the discipline and thehierarchy in a critical situation allowed an effective andfast intervention in the phase of installation and conso-lidation of the camp in spite of the difficulties met.These difficulties are due to human factors, including

• The large number of stakeholders and their dispa-rity: UN agencies, NGOs, volunteers…

• The heterogeneity of the population of the camp:different nationalities, cultures and religions…

• The camp life: television networks, journalists,national and international officials visits, unwantedvisitors and curious people…

• Besides, there are problems of security seen in thedistribution of cooking kits by a NGO containingstoves, electric and metallic knives (bladed weapons).This incites the refugees to cook in tents with a big firerisk.

However, it is necessary that certain military acquiredtraining in the crisis management based on predefinedscenarios. This training aims at acquiring:

a. Legal knowledge and the capacity to apply thehumanitarian principles.

b. Multidisciplinary technical knowledge in theconception of the high-density temporary camps.

c. Control of the humanitarian standards requestedby the international institutions.

d. Optimize the decision-making in crisis situations.

The planning of a camp of refugee is a multidisciplinaryeffort that asks for skills in engineering associated tooperational knowledge regarding humanitarian ser-vices such as health, logistics, water, education, com-munity services and purification of the environment.These were essential trump cards in the first stages ofthe installation of a camp.


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Photo 17: Viper «Cerastes cerastes».Photo 15: Cleaning and disinfection of toilet type A.

Photo 16: Disinsection by fumigation.


The early supply of drinking water and adapted toi-lets are essential to avoid the epidemics directlybound to a bad hygiene. Preservation of water qua-lity, the guarantee of hygiene and the safe disposal ofhuman excreta, sewage and garbage are interdepen-dent and linked to the health and well-being of thepopulation.

SUMMARY

February 20, 2011 Tunisian-Libyan border was invadedby tens of thousands of refugees.The Tunisian army was given the enormous task to preparea suitable camp as quickly as possible. The fundamentalobjective of a refugee camp is the preservation of thehealth of the displaced. Physical, moral and social well-beings of the refugees must be cared for. In addition, arefugee camp provides the refugees with adequateshelter, medical care, clean water, food and a healthyenvironment.The mission of military veterinarians was to participatein camp management and to coordinate the work ofNGOs and UN agencies in order to:

• Prevent foodborne illness,• Prevent the dissemination of waterborne diseases,• Promote the hygiene,• Promote waste management in accordance with

Tunisian law,

• Control the vectors, insects and rodents.The design of a refugee camp requires a multidisciplinaryeffort based on a spirit of cooperation between all stake-holders. For Tunisian military veterinarians it was aunique and exceptional experience during which theyconfirmed their ability to manage risks related to veterinarypublic health despite the difficulties.

RÉFÉRENCES BIBLIOGRAPHIQUES

1. Académie vétérinaire de France. la santé publique vétérinaire.www.academie-veterinaire-defrance.org

2. Chawki BACCARI. Gestion du camp de refugiés deChoucha « hygiène et environnement ». Diplôme demastère professionnel intégration du système de managementqualité, hygiène et environnement. 2011.

3. Jean-Philippe CHIPPAUX. Venins de serpent et envenima-tions. IRD Editions 2002.

4. Le Projet Sphère. Charte humanitaire et normes minimalespour les Interventions lors de catastrophes. Édition 2004.

5. Ministère de la Santé Publique Tunisien. Situation des réfu-giés à la frontière tuniso-libyenne. Bulletins de Santé 2011.

6. Mounir JEBALI. les scorpions en Tunisie, importance,impact et moyens de lutte. 4ème cours Internationale duCIMM pour les Vétérinaire et le personnel ParaVétérinaire. Tunisie 2008.

VOL.87/1


Pour plus d’informations, rendez-vous surPour plus d’informations, rendez-vous sur ::

www.cimm-icmm.orgwww.cimm-icmm.org

11erer COURS DE LA GESTION ET LA SECURITECOURS DE LA GESTION ET LA SECURITESANITAIRE DES EAUXSANITAIRE DES EAUX

Tunis (Tunisie)Tunis (Tunisie)

du 28 avril au 16 mai 2014du 28 avril au 16 mai 2014



VOL. 87/1

INSTRUCTIONS TO AUTHORS

• All material intended for publication in the International Review ofthe Armed Forces Medical Services (IRAFMS) should be submitted to theEditor’s office :

International Committee of Military MedicineHôpital Militaire Reine AstridBE - 1120 Brussels, Belgium.

• Scientific articles, analyses or reviews of books and articles related tomilitary medicine, symposia or congress proceedings, scientific eventsand announcements written in French, English or Spanish will beconsidered.

• Full name(s), address (es), short curriculum vitæ and photograph(s) ofthe author(s) should accompany each contribution.

• The authors implicitely recognize that the proposed documents havenot been sent simultaneously to other journals or have not beenrecently published under the same title.

• The Editor of the IRAFMS may require authors to justify the assignmentof authorship.

• All partial or complete reproductions of an article which has beenpublished in the IRAFMS are submitted to the previous agreement ofthe Editor of the IRAFMS.

• Manuscripts should be typewritten on one side only, double-spacedthroughout, with a 3 cm margin at the left hand side and a maximumof 35 lines. The text should not exceed 25 typewritten pages, includingbibliographic references. It should be submitted on A4 paper (Word formatArial 12) via e-mail to [email protected] or via postal service onCD-Rom with a printing proof.

• A summary of no more than 150 words should be include. It would bedesirable to submit the summary in both French and English (Spanish adlibitum).

• Three to five keywords should be provided in order to assist indexersin cross-indexing the article.

• Abbreviations should be avoided in the text except for accepted scientificunits of measurements (SI units). Other abbreviations, if used, should bespelt out in full when first mentioned in the text.

• When sending their manuscripts, the authors are invited to includethe necessary tables and illustrations. Drawings and legends should becarefully printed so as to be directly reproduced. Each illustrationshould be identified by writing a figure number or a short mention onthe back.

• References should be numbered in the order in which they appear inthe text and referred to by Arabic numerals in brackets. They are listedas follows :1. For a journal : author’s name and initials, full title of the article (in theoriginal language), title of the journal, year of publication, volumenumber, first and last page numbers.2. For a book : author’s name and initials, title of the book, name of thepublisher and city, year of publication, pages corresponding to thequotation.

RECOMMANDATIONS AUX AUTEURS

• Tout travail destiné à la publication dans la Revue Internationale desServices de Santé des Forces Armées (RISSFA) doit être envoyé auBureau de la rédaction :

Comité International de Médecine MilitaireHôpital Militaire Reine AstridBE - 1120 Bruxelles (Belgique)

• Sont pris en considération les articles scientifiques, les analyses d’ou-vrages ou d’articles médico-militaires, les comptes rendus de réunions,congrès, événements scientifiques et les annonces, rédigés en français,anglais ou espagnol.

• Tous ces travaux doivent être accompagnés des noms, adresse, brefcurriculum vitæ et photo du (ou des) auteurs(s). Ceux-ci reconnaissentimplicitement que le document proposé n’a pas été envoyé en mêmetemps à d’autres revues ou qu’il n’a pas été publié récemment sous lemême titre.

• La Direction de la RISSFA se réserve le droit, dans certain cas, dedemander au signataire d’un écrit la justification de sa qualité d’auteur.

• Toute reproduction partielle ou totale d’un article paru dans la RISSFAest soumise à l’accord préalable de l’Éditeur de cette dernière.

• Le manuscrit sera dactylographié en double interligne, marge gauche de3 cm, 35 lignes par page, sur le recto seulement et n’excédera pas 25 pages,références bibliographiques comprises. Il sera envoyé format A4 (Word,Arial 12), soit par e-mail à l’adresse suivante: [email protected] oupar voie postale sur CD-Rom accompagné d’une epreuve papier.

• Le résumé de l’article rédigé en français et anglais (espagnol ad libitum)ne dépassera pas 150 mots, et sera accompagné de la traduction du titredans ces deux langues.

• Il est indispensable de fournir 3 à 5 mots-clés en anglais et en françaisafin de faciliter l’indexation de l’article.

• Les abréviations doivent être évitées dans le texte, sauf celles se rap-portant aux unités scientifiques de mesure, dûment acceptées (unitésSI). Si d’autres abréviations sont utilisées, elles doivent être précédéesde la terminologie complète à laquelle elles se rapportent, lorsqu’ellessont mentionnées dans le texte pour la première fois.

• Les auteurs sont invités à inclure, dans l’envoi de leur manuscrit, lestableaux, graphiques, photos et illustrations indispensables accompagnésde leurs légendes. Les dessins et légendes, soigneusement exécutés,devront pouvoir être reproduits directement. Chaque figure sera iden-tifiée par une mention permettant de l’inclure correctement dans letexte.

• Les références seront inscrites dans l’ordre dans lequel elles paraissentdans le texte et indiquées par des chiffres arabes, entre parenthèses.Elles seront mentionnées comme suit :1. Pour un périodique : nom et initiales des prénoms de tous les auteurs,titre de l’article (dans la langue originale), nom du périodique, année,volume, page initiale et page finale de l’article.2. Pour un livre : nom et initiales des prénoms du ou des auteurs, titredu livre, nom de la maison d’édition, ville et année de publication,pages correspondant à la citation.

ADDRESS FOR SUBSCRIPTION

SUBSCRIPTIONS 2014International Review of the Armed Forces Medical Services

N.E.P.13, rue Portefoin - FR-75003 Paris, France

Tel. : +33 (0)1 40 27 88 88 - Fax : +33 (0)1 40 27 89 43E-mail : nep@wanadoo. fr

Credit Lyonnais : 7828 H - Paris Haxo (N.E.P.)

Subscription for one year : € 60Cost for a single copy : € 20

ADRESSE POUR LES ABONNEMENTS

ABONNEMENTS 2014Revue Internationale des Services de Santé des Forces Armées

N.E.P.13, rue Portefoin - FR-75003 Paris (France)

Tél. : +33 (0)1 40 27 88 88 - Fax : +33 (0)1 40 27 89 43E-mail : nep@wanadoo. fr

Crédit Lyonnais : 7828 H - Paris Haxo (N.E.P.)

Abonnement pour 1 an : € 60Prix du numéro ordinaire : € 20

I.S.S.N. : 0259-8582 Imprimerie dans l’Union européenne

Recommandations aux Auteurs_Mise en page 1 13/03/14 18:48 Page1


VOL. 87/1

INSTRUCTIONS TO AUTHORS

• All material intended for publication in the International Review ofthe Armed Forces Medical Services (IRAFMS) should be submitted to theEditor’s office :

International Committee of Military MedicineHôpital Militaire Reine AstridBE - 1120 Brussels, Belgium.

• Scientific articles, analyses or reviews of books and articles related tomilitary medicine, symposia or congress proceedings, scientific eventsand announcements written in French, English or Spanish will beconsidered.

• Full name(s), address (es), short curriculum vitæ and photograph(s) ofthe author(s) should accompany each contribution.

• The authors implicitely recognize that the proposed documents havenot been sent simultaneously to other journals or have not beenrecently published under the same title.

• The Editor of the IRAFMS may require authors to justify the assignmentof authorship.

• All partial or complete reproductions of an article which has beenpublished in the IRAFMS are submitted to the previous agreement ofthe Editor of the IRAFMS.

• Manuscripts should be typewritten on one side only, double-spacedthroughout, with a 3 cm margin at the left hand side and a maximumof 35 lines. The text should not exceed 25 typewritten pages, includingbibliographic references. It should be submitted on A4 paper (Word formatArial 12) via e-mail to [email protected] or via postal service onCD-Rom with a printing proof.

• A summary of no more than 150 words should be include. It would bedesirable to submit the summary in both French and English (Spanish adlibitum).

• Three to five keywords should be provided in order to assist indexersin cross-indexing the article.

• Abbreviations should be avoided in the text except for accepted scientificunits of measurements (SI units). Other abbreviations, if used, should bespelt out in full when first mentioned in the text.

• When sending their manuscripts, the authors are invited to includethe necessary tables and illustrations. Drawings and legends should becarefully printed so as to be directly reproduced. Each illustrationshould be identified by writing a figure number or a short mention onthe back.

• References should be numbered in the order in which they appear inthe text and referred to by Arabic numerals in brackets. They are listedas follows :1. For a journal : author’s name and initials, full title of the article (in theoriginal language), title of the journal, year of publication, volumenumber, first and last page numbers.2. For a book : author’s name and initials, title of the book, name of thepublisher and city, year of publication, pages corresponding to thequotation.

RECOMMANDATIONS AUX AUTEURS

• Tout travail destiné à la publication dans la Revue Internationale desServices de Santé des Forces Armées (RISSFA) doit être envoyé auBureau de la rédaction :

Comité International de Médecine MilitaireHôpital Militaire Reine AstridBE - 1120 Bruxelles (Belgique)

• Sont pris en considération les articles scientifiques, les analyses d’ou-vrages ou d’articles médico-militaires, les comptes rendus de réunions,congrès, événements scientifiques et les annonces, rédigés en français,anglais ou espagnol.

• Tous ces travaux doivent être accompagnés des noms, adresse, brefcurriculum vitæ et photo du (ou des) auteurs(s). Ceux-ci reconnaissentimplicitement que le document proposé n’a pas été envoyé en mêmetemps à d’autres revues ou qu’il n’a pas été publié récemment sous lemême titre.

• La Direction de la RISSFA se réserve le droit, dans certain cas, dedemander au signataire d’un écrit la justification de sa qualité d’auteur.

• Toute reproduction partielle ou totale d’un article paru dans la RISSFAest soumise à l’accord préalable de l’Éditeur de cette dernière.

• Le manuscrit sera dactylographié en double interligne, marge gauche de3 cm, 35 lignes par page, sur le recto seulement et n’excédera pas 25 pages,références bibliographiques comprises. Il sera envoyé format A4 (Word,Arial 12), soit par e-mail à l’adresse suivante: [email protected] oupar voie postale sur CD-Rom accompagné d’une epreuve papier.

• Le résumé de l’article rédigé en français et anglais (espagnol ad libitum)ne dépassera pas 150 mots, et sera accompagné de la traduction du titredans ces deux langues.

• Il est indispensable de fournir 3 à 5 mots-clés en anglais et en françaisafin de faciliter l’indexation de l’article.

• Les abréviations doivent être évitées dans le texte, sauf celles se rap-portant aux unités scientifiques de mesure, dûment acceptées (unitésSI). Si d’autres abréviations sont utilisées, elles doivent être précédéesde la terminologie complète à laquelle elles se rapportent, lorsqu’ellessont mentionnées dans le texte pour la première fois.

• Les auteurs sont invités à inclure, dans l’envoi de leur manuscrit, lestableaux, graphiques, photos et illustrations indispensables accompagnésde leurs légendes. Les dessins et légendes, soigneusement exécutés,devront pouvoir être reproduits directement. Chaque figure sera iden-tifiée par une mention permettant de l’inclure correctement dans letexte.

• Les références seront inscrites dans l’ordre dans lequel elles paraissentdans le texte et indiquées par des chiffres arabes, entre parenthèses.Elles seront mentionnées comme suit :1. Pour un périodique : nom et initiales des prénoms de tous les auteurs,titre de l’article (dans la langue originale), nom du périodique, année,volume, page initiale et page finale de l’article.2. Pour un livre : nom et initiales des prénoms du ou des auteurs, titredu livre, nom de la maison d’édition, ville et année de publication,pages correspondant à la citation.

ADDRESS FOR SUBSCRIPTION

SUBSCRIPTIONS 2014International Review of the Armed Forces Medical Services

N.E.P.13, rue Portefoin - FR-75003 Paris, France

Tel. : +33 (0)1 40 27 88 88 - Fax : +33 (0)1 40 27 89 43E-mail : nep@wanadoo. fr

Credit Lyonnais : 7828 H - Paris Haxo (N.E.P.)

Subscription for one year : € 60Cost for a single copy : € 20

ADRESSE POUR LES ABONNEMENTS

ABONNEMENTS 2014Revue Internationale des Services de Santé des Forces Armées

N.E.P.13, rue Portefoin - FR-75003 Paris (France)

Tél. : +33 (0)1 40 27 88 88 - Fax : +33 (0)1 40 27 89 43E-mail : nep@wanadoo. fr

Crédit Lyonnais : 7828 H - Paris Haxo (N.E.P.)

Abonnement pour 1 an : € 60Prix du numéro ordinaire : € 20

I.S.S.N. : 0259-8582 Imprimerie dans l’Union européenne

Recommandations aux Auteurs_Mise en page 1 13/03/14 18:48 Page1

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