ADF Health 2010

ADF Health | Vol 11 No. 1 | 2010 1

Contents 3 Editorial: ‘Caring for People’

MAJGEN Jeffrey V Rosenfeld

7 More on the Staff and Serpent of Asclepius CMDR John Frith

9 Literature Review: The most effective method of cooling a soldier suffering from exertional heat stroke LT Rachel Louise McKenzie

15 War and Disease: War Epidemics in the Nineteenth and Twentieth Centuries Air Vice Marshal Bruce Short AM RFD

19 Pure Massacre: Aussie soldiers reflect on the Rwandan Genocide Air Vice Marshal Bruce ShortAM RFD

21 Mild hypothermia in the battle casualty’ MAJ Ken Wishaw

25 Management of IED Injury: A Case Reflective of Contemporary Treatment and Understanding of Resources Required to Save Life COL Andrew M. Ellis OAM RAAMC FRACS (Orth) FAOrthA

Senior Health Advisor 2DIV LTCOL Fran Smith RAAMC FRACP FANZCA FCICM Standby Reserve

34 Australian Defence eHealth – JeHDI

35 The Military Health Outcomes Program (MilHOP

40 ADF Paralympic Sports: Striving to win against all odds

42 AMMA Program

S T R E N G T H E N I N G H E A L T H I N D E F E N C E

Journal of the Australian Defence Health ServiceADF Health

Front Cover: Royal Australian Navy personnel undergoing simulation training for mass casualty event.


Journal of the Australian Defence Health ServiceISSN 1443-1033

Editorial Board

Editor and Chairman, Editorial Board Major General J.V. Rosenfeld MB BS, MD, MS, FRACS, FRCS(Edin), FACS, FRCS(Glasg) Hon, FACTM, MRACMA Surgeon General Defence Health Reserves

Assistant Editors Group Captain P.S. Wilkins MBE, BA, MB BS, MHP, Mlitt, FRACMA, FAFOM, FAFPHM

Major M.B. Tyquin PhD, BEc, BA(Hons), MStJA, MPHA

Captain M.C. O’Connor AM, MB BS(Hons), MD, DCH, DDU, FRCOG, GRANZCOG, JP, RANR

Professor G.D. Shanks BS, MD, MPH, FACTM, Director Army Malaria Institute

Lieutenant Colonel K.L. Clifford RN, GradCertEmerg, GradDipMid, MPH, MRCNA, MCN, AFCHSE, RAANC

Associate Professor S.J. Neuhaus CSC, MB BS, PhD, FRACS

Group Captain A.C. McFarlane MB BS (Hons), MD, FRANZCP, Dip Psychother

Professor P. Warfe CSC, CStJ, MB BS, MTM&H, FAFPHM, FACTM, FACPsychMed, psc, RAAMC

Editorial Consultants Major General Professor J.H. Pearn AO, RFD, MD, BSc, PhD, FRACP, FRCP, FACTM, FAIM

Air Vice Marshal B.H. Short AM, RFD, MB BS, FRACP, FCCP, FACP, FACTM

Production ManagerClaire Henry

Publication AdministratorCAPTAIN Brendan Byrne RAN BDS,MMDS,MBA,Grad Dip MS, psc(j), Director Defence Force Dentistry

ADF Health is published once a year by Adbourne Publishing for the Australian Defence Health Service. All members of the Defence Health Service are eligible for a free subscription to ADF Health.

For subscription requests and enquiries, contact Captain Brendan Byrne, Defence Health Service, CP2-6-065, Campbell Park Offices, CANBERRA ACT 2600. Fax: (02) 6266 2143 Email: [email protected]

The statements or opinions that are expressed in the Journal reflect the views of the authors and do not represent the official policy of the Defence Health Service unless this is so stated. Although all accepted advertising material is expected to conform to ethical and legal standards, such acceptance does not imply endorsement by the Journal.

All literary matter in the Journal is covered by copyright, and must not be reproduced, stored in a retrieval system, or transmitted in any form by electronic or mechanical means, photocopying, or recording, without written permission.

AdbourneP U B L I S H I N G

Caring for people

Defence health personnel have an outstanding

record of caring for sick and injured members of the Australian Defence Force (ADF) in Garrison or on deployed operations. Defence Health personnel also provide humanitarian assistance including health care to the local civilian population on overseas operations and help to win their ‘hearts and minds’. ADF Health personnel are great ambassadors for the ADF and Australia.

Another very important role for our Health Personnel is to ensure that our combat medics and soldiers are able to provide high level combat first aid care on the front line for missions overseas. This has been very important in Afghanistan where improvised explosive devices (IED’s) have caused fatalities and serious injuries in remote, austere environments. All of the soldiers who deploy are receiving combat first aid training at a high level with rehearsal scenarios and realistic training delivered by senior experienced Reservists and permanent ADF staff. Our Royal Australian Airforce personnel are caring for our wounded soldiers on return flights from Afghanistan via Germany on our C17 transport aircraft, and in doing so are providing continuous intensive care during the flight. All of this advanced and timely care saves lives and improves outcomes. Much thought is going in to develop our new Concepts of Operation (CONOPS) based on the current evidence base, learning the lessons from past missions and incorporating new concepts of care which have been used successfully by our coalition partners. We also have senior Reservists working closely with our ADF staff to treat and rehabilitate our injured soldiers on their return from Afghanistan and other overseas operations. The exciting developments of expanded and better integrated services in defence mental health and rehabilitation services will go a long way towards maximising the recovery of our injured soldiers.

Defence Health personnel are deployed on many of our overseas operations including Afghanistan, Solomon Islands, Timor and more recently in the Punjab region of Pakistan. Reservists play a vital role in all of these operations. The ADF with the support of AusAID had provided assistance to

ADF Health

Adbourne Publishing Pty LtdPO Box 735, Belgrave, Victoria 3160Tel: (03) 9758 1433Fax: (03) 9758 1432Email: [email protected]

continues next page >

4 ADF Health | Vol 11 No. 1 | 2010

more than 5,000 people affected by the Pakistan floods by the end of September 2010. Camp Cockatoo, the Australian base and field hospital 80 kilometres north west of Multan is home to more than 170 defence and AusAID personnel. We will in the future see increased deployment of combined civilian (State Government) disaster teams, Department of Foreign Affairs officers, other public servants, and ADF military health, engineering and logistic personnel providing comprehensive support in disaster zones. It is great to see civilian health and logistic personnel working closely with their ADF colleagues in disaster zones such as Pakistan. Clearly the rapid lift and deployment capability of the ADF is essential in ensuring rapid disaster response. This complements the already close relationship between Defence and the Australian Federal Police in many of the operations which have occurred in our peacekeeping operations over the last decade.

There is also currently a major focus on preventive health throughout the Australian Defence Force and this has particularly been brought home by our senior officers including Chief of Army (CA) who has recently spoken publicly about men seeking timely preventive health measures including painting his face blue to remind men to ‘face up to’ taking their health seriously and changing how they approach illness. CA makes the important point that Cancer kills more men each year than soldiers in combat. CA has changed the regulations on wearing berets because he is rightly concerned about the risk of skin cancer in our personnel who are often exposing themselves to the sun for many hours in the day. The brimmed Army hat (HKFF) provides much more protection than the beret. The RSM of the Army WO1 Stephen Ward has been promoting the new policy

and explaining it to members who still stubbornly wish to wear the berets. Members of the ADF have to realise that the ADF has a ‘duty of care’ towards them which includes preventive health measures. It is part of our duty as ADF Health Professionals to promote occupational health and safety and preventive health measures in our day-to-day work and to support and help deliver the policies of the

senior leadership in the ADF.

In this issue of ADF Health there are a number of informative articles including McKenzie’s review of heat stroke. Clearly this has implications for life-saving preventive health measures. Wishaw’s article on hypothermia also has strong implications for preventive health policy as well as therapy for those affected. Our personnel do frequently work out in the field in environmental extremes and health personnel working with them need to educate these personnel and their commanders about the issues of prevention and treatment of heat stroke and hypothermia.

AVM Short presents an interesting article on war and disease and from this there are many historical lessons which can inform health personnel and the military leadership of today. The book he reviews on the extraordinary work of our personnel in Rwanda following the genocide shows how our people were caring for the weakest and poorest humans in the worst of circumstances. It is a powerful story indeed. Ellis provides an informative article based on the Afghanistan experience to highlight the modern principles of treating battle casualties exposed to bomb blast and other penetrating trauma. No doubt this level of high quality care provided to our personnel in Afghanistan from the point of wounding back to Australia is saving lives and reducing morbidity and future suffering.

Thank you to all our readership for your ongoing service to the ADF and the nation. It is much appreciated. I wish you all a Merry Christmas and Happy New Year. Please keep the articles flowing to ‘ADF Health’. We do need more articles.

This is your journal. Please support it.

Jeffrey V RosenfeldMAJGEN

Surgeon General Defence Health Reserves

Editor, ADF Health

EDITOR’S MESSAGE

It is part of our duty as ADF

Health Professionals to promote

occupational health and safety and

preventive health measures in our

day-to-day work and to support

and help deliver the policies of the

senior leadership in the ADF.


Asclepius, the Greek god of healing and the son of Apollo, was revered as a forefather of the art of medicine in the many centuries before and after Hippocrates, and his symbol, the staff and serpent, has come to represent medicine, the healing profession. Asclepian medicine after the fifth century BC took place in an era of change of Greek and Roman medicine from being wholly based on magic and religious rituals to an objective approach with history taking and recording and examination of body parts, and treatment using diet, mineral baths, exercise, and plant and herbal treatments. There are several interpretations of the meaning of both the knotted wooden staff and the serpent, they both represent healing powers, but rational as well as supernatural.

Asclepius and follower physiciansAsclepius is portrayed on ancient statures and reliefs as a bearded, mature, noble and benevolent man, draped in a simple toga, and holding a knotted wooden staff around which is entwined a serpent with magical healing powers – the “staff of Asclepius” (1, 2, 3). Asclepius was probably a historical human figure in 1250 BC and his sons, Machaon and Podalirius, are mentioned as military physicians in Homer’s Iliad of eighth century BC (4, 5). He was worshipped as a cult leader of the art of healing in ancient Greece and Rome for many centuries and deified as the god of medicine in the fifth century BC.

The itinerant practitioners of Asclepian medicine were called ‘periodeutae’ and regarded disease as disharmony between the body (‘corpus’) and nature (‘physis’) (6). Asclepian practitioners would orate and sing and invite people to their ‘iatreia’, or offices, where they practiced their art of ‘pronoea’, obtaining from the ill person a detailed account of their symptoms then giving them a diagnosis and prognosis of their ailment. When more rational medicine and therapeutics, such practitioners had professional status practising the art of healing, or ‘physik’, returning a person’s health back to its natural state.

History

More on the Staff and Serpent of AsclepiusCMDR John Frith

CMDR John Frith joined the RAN Reserve as a Surgeon-Lieutenant at HMAS Waterhen in 1977 and did his initial Reserve Officers’ training at HMAS Creswell. His postings have included medical officer on HMA Ships Vendetta and Supply, in Naval hospitals at HMAS Cerberus, Albatross, and Penguin and other Naval shore establishments, and duties with the Directorate of Naval Health. He has been a medical

officer and instructing staff on Naval and Army Reserve medical exercises, and has completed training in aviation medicine and nuclear, chemical, and biological medicine. His civilian work interests have included private general practice and university lecturer in general practice, environmental health and public health. He has retired from full-time teaching but is currently a Visiting Fellow in the School of Safety Science at the University of New South Wales.


Asclepian temples and ‘incubation’ therapyPeople who couldn’t afford a physician could have their illnesses, wounds and ailments attended to and cured in Asclepian temples, or ‘Asclepieia’. The temples were elaborate sanatoriums and an idyllic and hypnotic environment attended to by Asclepian priests and their magical healing serpents. ‘Temple sleep’ was a previously known form of ritual treatment practised in ancient Egypt by physician followers of the Egyptian god of healing, Imhotep (2). Asclepieian treatment was not just based on ritual and interpretation of dreams, but also natural forms of therapy such as purgatives, absence from alcohol, dieting, massage, exercise, mineral baths, and herbal and plant medicinal treatments.

An ill person would first have a purifying mineral bath, perhaps a purgative and fasting, and sacrificial offerings were made. Non-venomous ‘sacred serpents’ which were revered for their magical healing and rejuvenation powers roamed free and would lick the person’s wound or lesion or eyes. The patient went to sleep, possibly with the help of snake venom, in the ‘abaton’, a long colonnade of ‘cubicles’ which were open to the air, and Asclepius and his daughters, Panacea and Hygiea,

would visit the person in their dreams and prescribe a cure. When they awoke a priest would interpret their dreams and advise on the treatment prescribed by Asclepius. (1, 2, 3).

The magical serpentThe serpent has its origins as a symbol of magic and healing in more ancient times than Asclepius, and was symbolic of medicine in ancient Sumerian, Egyptian, Minoan and Mycenaean cultures. In Asclepian times the serpent came to represent wisdom, rejuvenation, longevity and immortality, perhaps related to its ability to shed skin and grow, as well as health and cure of disease. They were used to discover medicinal herbs and their venom may have been used therapeutically in the Asclepian temples. (7, 8, 9, 10)

The knotted wooden staffThe staff assisted Asclepius in his wanderings from place to place curing illnesses, and it may have also represented sacred trees and plants that had natural and magical healing powers (9, 10). The staff has long been used symbolically as a symbol of wisdom and a mark of profession by priests, prophets, philosophers, scientists and physicians. Medical history references do not say what the Asclepian staff was made of, although in the time the islands of Cos and Delos were abound with olive and orange trees.

ConclusionAsclepian medicine spanned a long period of history of the ancient Greek-Roman world. It was originally based on sacred religious ritual and the magical healing powers of the serpent, but also developed a rational approach to diagnosis and treatment using treatments such as diet, physical therapies and plant medicinals. The symbol of Asclepius, the staff and serpent, has since come to represent medicine, and wisdom, knowledge, skill and benevolence, and is an apt symbol for practitioners of the art of healing.

References1. Castiglioni A. A History of Medicine. New York: Alfred A Knopf,

1946.

2. Guthrie D. A History of Medicine. London: Thomas Nelson & Sons Ltd, 1947,

3. Singer C, Underwood EA. A Short History of Medicine. 2nd edition. Glasgow: Oxford University Press, 1962.

4. Ackerknecht EH. A Short History of Medicine. Revised edition. Baltimore: John Hopkins University Press, 1968.

5. MedicineNet. Definition of Asclepius. http://www.medterms.com/script/main/art.asp?articlekey=33627 (accessed on 23.12.08).

6. Marti-Ibanez F. A Pictorial History of Medicine. London: Spring Books, 1962.

7. Blayney K. The Caduceus vs the Staff of Asclepius (Asklepian). October 2005. http://www.drblayney.com/Asclepius.html (accessed on 7.2.09).

8. Hinek A, Backstein R. The magic wands of medicine. University of Toronto Medical Journal 2004; 82 (1): 68-70.

9. Williams NW. Serpents, staffs, and the emblems of medicine. JAMA 1999; 281 (5): 475.

10. WordInfo. Aesculepius, Asculapius (Latin); Asclepius, Asklepios (Greek). http://www.wordinfo.info/words/index/info/view_unit/2876 (accessed on 23.12.08).

Statue of Asclepios of the Este type. Pentelic marble, Roman period copy of ca. 160 AD after a 4th-century BC original. From the temple of Asclepios at Epidaurus (National Archaeological Museum, Athens, inv. 263)


AbstractSoldiers are often physically pushed to their limits in order to prepare and condition themselves to survive in war. In hot climates this physical exertion can lead to exertional heat stroke (EHS). Rapid and efficient cooling is the most important therapeutic objective in patients with EHS. The purpose of this review is to find the most effective method of cooling a soldier suffering from EHS. The literature search conducted included articles between 1985 and 2009. The databases searched were CINAHL plus, Cochrane Library, Science Direct, Pub Med, Ovid, Medline and Proquest. A manual search of reference lists was also conducted. Literature was included if it contained comparisons of different cooling methods in either patients with EHS or normal participants who were subjected to heat stress in experiment conditions. A total of 15 articles were selected. Careful analysis of the articles obtained indicated that the most effective method of cooling a soldier suffering from EHS is ice water immersion. In conclusion the evidence presented supports the Australian Defence Forces new Health Directive that advocates the use of ice water immersion. It is also evident from the literature that further prospective studies would be beneficial as they examine actual EHS cases rather than healthy participants in experiment conditions.

Keywords: heat stroke, exertional heat stroke, heat illness, cooling techniques, ice water immersion and military.

IntroductionIn 2008 the Australian Defence Force (ADF) introduced a new Health Directive to manage and treat heat casualties within the Defence Force.1 Heat hazards pose a significant threat to Defence personnel due to the nature of work and training, therefore exposure to high levels of heat stress is imminent. Currently, the ADF has preventative measures in place to help in the prevention of heat stress such as heat acclimatization, fluid and electrolyte replacement, exercise/rest guidelines, using the early hours of morning for strenuous

Literature Review

The most effective method of cooling a soldier suffering from exertional heat strokeLT Rachel L. Mckenzie

LT Rachel Louise Mckenzie has been the Nurse Unit Manager at the School of Infantry Singleton since 2005. Her nursing background is Emergency and Primary Health Care. She joined the Army Reserves in 1998 as a medic and is currently a Nursing Officer with the 12/16th Hunter River Lancers. She holds a Masters Degree in Nursing. Her interests are emergency management and heat illness.

activity to avoid the day time heat and vigilance, EHS can still occur. EHS is defined as a life threatening condition that occurs when the accumulation of heat dramatically exceeds the body’s ability to dissipate heat due to a failure of the hypothalamus.2 Characteristics of heat stroke include a core body temperature of greater than 41.0ºCelcius (C), dry skin, hypotension, tachycardia, neurological dysfunction such as delirium, confusion, convulsions, unconsciousness and coma.1-4 When the core body temperature reaches critical levels, body organ systems begin to fail. The prognosis for EHS depends upon the length of time and degree that the core temperature is elevated. The definitive management goal of EHS is to reduce the core body temperature to a safe level of below 38.5ºC as quickly as possible.

The purpose of this literature review is to determine the most effective cooling method for a soldier suffering from EHS. The review will focus on cooling methods and provide comparisons of cooling times used for EHS. The second purpose for this review is to explore evidence that may support the new ADF Health Directive1 which encourages the use of ice water immersion in the treatment of EHS.

MethodA comprehensive search of the literature was carried out using the databases CINAHL plus, Cochrane Library, Science Direct, Pub Med, Ovid, Medline and ProQuest. The search terms that were used; heat stroke, exertional heat stroke, heat illness, cooling techniques and ice water immersion. Keywords were

used on their own and with the word military added to find specific articles. Limits were also placed on the search being human subjects and published after 2000. A manual search of reference lists was also conducted and from this several articles of relevance were found that were dated pre 2000. Therefore the search limits were extended to 1985 –current. These studies were included as they are directly related to the topic for investigation and they support the more current literature selected for the review. Literature was included if it contained comparisons of different cooling methods in either patients with heat stroke or normal participants who were subjected to heat stress in experiment conditions. Articles were based on soldiers and athletes as both groups have similar physical characteristics such as fit, healthy and athletic. A total of 15 articles were selected.

DiscussionThe main objective in the management of EHS is to reduce the body temperature to a safe level as quickly as possible. The two main forms of cooling utilised and discussed in the literature to date are conduction and evaporative methods:

1. Conduction is the passive transfer of heat from the body into the surrounding air, liquid or solid in contact with the skin along a temperature gradient.3 Conduction cooling includes methods such as cold water immersion, ice water immersion, application of ice packs and cooling vests.

2. Evaporative cooling is based on the physical principle that the conversion of water on the skin to a gaseous phase consumes


heat.3 Therefore as air is forced onto the skin when wet it will consume some of the heat from the body. Evaporative cooling can include fan forced, sitting the patient in the shade, fanning and helicopter downdraft.

Several studies to date have directly compared conduction and evaporative methods.2, 4-7 Clements et al2 conducted a random crossover study to assess whether ice water immersion, cold water immersion or no immersion is the more effective cooling method in trained distance runners. Although this was limited in terms of the small homogenous sample (n =17) it clearly showed that ice water was faster than cold water in cooling a hyperthermic runner. It was also evident that ice water and cold water immersion were more effective than no immersion at all. With approval of the Local Institutional Review Board for Human Subjects, Armstrong et al4 also conducted a Randomized Control Trial (RCT) where twenty one distance runners completed an 11.5km race and were then randomly assigned to either conduction cooling (ice water immersion) or evaporative cooling (air exposure while wrapped in towels). Armstrong et al4 believe ice water immersion is the more effective cooling method and for that reason they randomly assigned 14 participants to ice water and only 7 to air exposure. This presents a threat to internal validity as the results are based on uneven randomisation of participants. The results of this study4 showed that ice water immersion cooled the runners twice as fast as air exposure. Armstrong et al4 present reliability in their study in that it can be repeated due to the nature of the independent variable (ice water immersion and air exposure) and the measuring instrument (rectal thermometer). Similar results were also found in other studies.5-7 Clapp et al5 conducted a repeated measure design study on five participants to determine which method of cooling is more effective between torso immersion in cold water, hands and feet immersion and sitting in the shade. The results revealed torso immersion to be most beneficial, evidenced by the cooling time of 0.25ºC/min, hands and feet 0.16ºC/min and sitting in the shade 0.11ºC/min. The small subject size (n=5) and homogenous sample does make it difficult to generalise the results.

Lopez et al6 conducted a study consisting of 10 participants. After exercising to a core temperature of greater than 38.7ºC half of the participants put on a cooling vest and half did not. The results showed the cooling vest was effective, however when the cooling time of the vest were compared to previous studies with ice water immersion, it was found that immersion was by far a more effective means to cool the body. Limitations to this study included females being excluded and all participants had to be a similar weight and height, therefore it is difficult to generalise the findings. Finally due to ethical and safety concerns the study limited the increase in core body temperature to less than 39ºC, which is in fact only mild hyperthermia, EHS occurs in core temperatures exceeding 41.0ºC.1

Taylor et al7 with approval from the Human Research Ethics Committee conducted a random cross over study in which eight healthy, physically active males participated. Once their core temperature reached 39.5ºC they were exposed to air, cold water immersion (14ºC) or temperate –water immersion (26ºC). The results found that cold water immersion was

the most effective. Reliability is achieved in this study as the instrument used (esophageal thermometer) meant there would be no carry over effects as the instrument is objective in nature. A limitation to this study is that it was conducted indoors in an air conditioned environment; thus threatening the internal validity as the air conditioning may affect the independent variable (cold and temperate water).

Although not comparing conduction and evaporation Proulx et al8 compares four different water temperatures 2ºC, 8ºC, 14ºC and 20ºC with seven healthy subjects. The participants exercised until their core temperatures reached 40ºC. Participants were exposed to all four water temperatures on four separate days. The results showed that the 2ºC water cooled the participants twice as fast as the other water temperatures. The limited size, selection criteria and controlled environment of a laboratory would make the results difficult to generalize. This again supports the evidence that cold/ice water immersion is the most effective cooling method. McDermott et al9 conducted an observational study for five consecutive years at Marine Corp marathons. During this period they observed the onsite treatment for nine EHS patients. Treatment consisted of dousing the patient in water and massaging their bodies with ice. The results found this form of cooling to be 70% as effective as cold water immersion. This study is limited in terms of sample size however the patients are direct examples of military members suffering EHS.

Costrini10 advocates the use of ice water immersion after he conducts a retrospective review of whole body cooling techniques. Costrini was a Marine Corps Medical Officer who treated 39 patients with EHS using an ice water bath. The patient’s temperatures ranged from 41.1ºC to 43.1ºC. The ice water bath resulted in a 0.15ºC/min decrease in core temperature. All patients returned to normal active duty with no renal or other organ failure. This study provides sound evidence that ice water immersion is the most effective as they are treating real life cases of heat stroke in the environment in which they occur. Harker and Gibson11 who are two Military Nursing Officers in the UK, reviewed rapid cooling techniques to support what practices are currently being used in military hospitals. They conducted an informal study on doctors and nurses (n = 25) within their own hospital all of which clearly preferred ice water immersion as a cooling method; they argue that the basic rational is that the ability of water to conduct heat is much greater than that of air.11

Several other studies12-16 all conclude that ice water immersion is the most effective method for treating EHS when compared to other forms of cooling such as ice packs, evaporation and intravenous fluids. Boucharma3 concludes that the cooling method based on conduction, namely ice water immersion started within minutes of the onset of EHS, was safe and effective in young, healthy well-trained military personnel or athletes.

Several studies 2, 5, 10, 12-14, 16 stress that treatment should begin at the time of collapse. Although ice water immersion may be the most effective method of cooling a soldier it is not practical in the field environment.10, 14 If a soldier collapses in the field and ice water immersion is not available in order to prevent further increase in temperature, removing excess clothing, placing in the shade, dousing in water and fanning


may be life saving measures until the casualty is evacuated to a medical facility where ice water immersion is practical. Studies7, 13 have also shown that temperate water does decrease core body temperature. Although not as effective as ice water immersion, soldiers do carry limited amounts of water for drinking and cleaning and this may be a life saving measure in the field environment. Soldiers can be hours away from a medical centre therefore O’Hara et al14 recommend further testing and implementation of the Carotid artery-cooling patch (CACP). The CACP is a small device carried easily in a soldiers pack and placed over the carotid artery in hot conditions. The CACP is based on cooling along the carotid artery and surrounding tissue which enhances blood flow to the head and neck and decrease the chances of brain ischemia.14 A limitation to this is there are no studies to date to support the use of the CACP. Smith’s systematic review of the literature12 also supports the use of ice water immersion however notes that it is impractical for soldiers in the field and athletes that collapse on the roadside and away from immediate medical attention. This review may be subject to publication bias as all included experiments had the desired outcome.

In reviewing the ADF Health Directive1 it is evident that it addresses to a degree, ice water immersion for soldiers in the field environment. On military bases an ice machine will be available and ten kilogram bags of ice will be prepared daily for pick up by all training platoons to take to the field for the day. The ice will be stored in an esky and will be utilised in the case of heat illness. A ‘hoochie’ (hoochie is a military slang term used to describe an individual soldiers sleeping shelter. It is a 2 metre by 4 metre water proof shelter carried by all soldiers) will be used as the immersion bath, by having other soldiers hold up the corners of the hoochie whilst the casualty lies in it and is covered with water and ice. This system is referred to in the ADF Health Directive1 as the ‘Taco method’ (due to the fact it looks like a taco) and may be enough to cool the patient until they reach medical help. Although this is a good method to adopt, the question remains as to how long the ice will stay frozen in 40ºC temperatures even in the esky. However even if it is only water, it is the coldest cooling mechanism available and the key element of EHS is to decrease core body temperature. In addition this review highlights the fact that although ice water immersion is the most effective method for cooling soldiers on military bases, other methods of cooling may need to be adopted in the field environment. Future research should focus on practical cooling devices that can provide rapid cooling effects of soldiers training in the field and working in war zones.

In reviewing the outcomes of the incorporated literature it also becomes evident that most of the quantitative literature is based on healthy volunteers in experimental conditions such as Randomised Controlled; cross over and repeated measure trials. Soldiers undergoing training are often sleep deprived, living on minimal food and sometimes already dehydrated, their bodies are already stressed and not functioning at peak condition. In contrast to this a healthy participant in an experiment is fit, healthy, well rested, hydrated and nourished. Therefore the question has to be raised; are healthy participants in EHS studies true reflections of EHS and can the results of these studies be used as sufficient evidence to support ice water immersion.

RCT’s are considered high quality in terms of evidence; however in relation to EHS it may be difficult to generalize the results. Six RCT’s were included in this review; 2, 4-8 all trials used participants who were healthy, young volunteers. They were exercised under experiment conditions until their core temp reached less than 40ºC in four of the studies2, 5-7 and 41ºC in two of the studies.4, 8 With heat stroke being defined earlier as a core temperature over 41ºC the issue is raised as to whether the four experiments with peak core temperatures of less than 40ºC can be used as substantial evidence. However in exploring this further it is hard evidence in the included RCT’s that ice water immersion is the most effective cooling method. Whether the patient’s temperature is 38ºC or 41ºC, ice water is going to be the most effective method of cooling based on the principle of conduction alone, irrespective of peak core temperature.

In addition to RCT’s, it would be worthwhile considering future research to be based on prospective cohort studies. For example if all ADF Health facilities record the outcomes and cooling times of real EHS patients over the next two years using ice water immersion and evaporative methods, the data collected could be used as substantial evidence of the effectiveness of ice water immersion. These cases are true reflections of EHS in soldiers and how the body adapts.

Implications to Nursing PracticeNursing staff working within the ADF are often faced with patients suffering from EHS due to the nature of military training. The potential significance of this literature review to nursing scholarship is that it will allow for the most effective and rapid method of cooling a soldier to be utilised. The focus group for this study is military personnel however the results of this literature review can be generalized to athletes in sporting events and marathons as they have similar physical characteristics. As can be seen from this literature review these results could potentially be used as part of the evidence to develop a national or even universal policy for treating heat illness. This review can be used as evidence to support the new ADF Health Directive into the management of EHS.

ConclusionMany methods exist to cool the body, primarily evaporative and conductive methods. From the literature presented current evidence strongly supports the use of ice water immersion. In triangulating the data obtained from this literature review although ice water immersion is the most effective, the practicality and logistics of this cooling method in the field environment is highlighted as an issue. The window of opportunity to provide immediate cooling post collapse is narrow and must be done with a modality that has sufficient cooling potential. Soldiers need to be trained in simple cooling methods that are logistically possible in the field such as fanning, removing clothing, dousing in water and where possible the ‘Taco method.’ If they are immediately evacuated to a medical centre where ice water immersion can commence their chances of survival are increased. Future research should focus on well designed prospective studies that examine the effect of ice water immersion on patient outcomes as well as studies to examine cooling methods that are practical and available in the field environment.

Conflict of InterestI Rachel L. Mckenzie declare there are no potential competing interests regarding this article.

ReferencesAustralian Government. Department of Defence. Health Directive 1. No 28: Health Management for the prevention and treatment of heat casualties within the Australian Defence Force: 2008. Available from: Defence Publications. Reference Online. http://defweb.cbr.defence.gov.au/home/documents/adfdocs/healthindex.htm.

Clements JM, Casa DJ, Knight CJ, McClung JM, Blake AS, Meenen 2. PM, Gilmer AM, Caldwell KA. Ice-water immersion and cold water immersion provide similar cooling rates in runners with exercise-induced hyperthermia. J Athl Train. 2002; 37(2):146-150.

Bouchama A, Dehbi M, Chaves-Carballo E. Cooling and hemodynamic 3. management in heatstroke: practical recommendations. Critical Care. 2007; 11:R54.

Armstrong LE, Crago AE, Adams A, Roberts WO, Maresh CM. Whole-4. body cooling of hyperthermic runners: comparison of two field therapies. Am J Emerg Med. 1996;14: 355-358.

Clapp AJ, Bishop PA, Muir I, Walker JL. Rapid cooling techniques 5. in joggers experiencing heat strain. J Sci and Med in Sport. 2001; 4(2): 160-167.

Lopez RM, Cleary MA, Jones LC, Zuri RE. Thermoregulatory 6. Influence of a cooling vest on hyperthermic athletes. J Athl Train. 2008; 43 (1): 55-61.

Taylor NA, Caldwell JN, Van Den Heuvel AM, Patterson MJ. To 7. cool, but not too cool: That is the question – Immersion cooling for hyperthermia. Med. Sci. Sports Exerc. 2008; 40 (11): 1962-1969.

Proulx CI, Ducharme MB, Kenny GP. Effect of water temperature on 8. cooling efficiency during hyperthermia in humans. J Appl Physiol. 2003; 94:1317-1323.

McDermott BP, Casa DJ, O’Connor FG, Adams WB, Armstrong LE, 9. Brennan AH, Lopez Rm, Stearns RL, Troyanos C, Yeargin SW. Cold-water dousing with ice massage to treat exertional heat stroke: a case series. Aviat Space Environ Med. 2009; 80 (8): 720-722.

Costrini A. Emergency treatment of exertional heatstroke and 10. comparison of whole body cooling techniques. Med. Sci. Sports Exerc. 1990; 22(1): 15-18.

Harker J, Gibson P. Heat Stroke: a review of rapid cooling techniques. 11. Int. Crit. Care Nurs. 1995; 11:198-202.

Smith JE. Cooling methods used in the treatment of exertional heat 12. illness. Br J Sports Med. 2005; 39:503-507.

Heled Y, Rav-Acha M, Shani Y, Epstein Y, Moran DS. The “Golden 13. Hour” for Heatstroke Treatment. Military Medicine. 2004; 169 (3):184-186.

O’Hara R, Eveland E, Fortuna S, Reilly P, Pohlman R. Current 14. and future cooling technologies used in preventing heat illness and improving work capacity for battlefield soldiers: Review of the Literature. Military Medicine. 2008; 173 (7):653-657.

McDermott BP, Casa DJ, Ganio MS, Lopez RM, Yeargin SW, 15. Armstrong LE, Maresh CM. Acute whole-body cooling for exercise-induced hyperthermia: A systematic review. J Athl Train. 2009; 44 (1): 84-93.

Rav-Acha M, Hadad E, Epstein Y, Heled Y, Moran D. Fatal Exertional 16. Heat Stroke: A Case Series. Am J Med Sci. 2004; 328 (2): 84-87.

Rachel L. Mckenzie, Nurse Unit Manager/Practice Manager

Singleton Military Area Medical Centre Lone Pine Barracks, Singleton NSW 2331

Ph. 02 65750414 Fax. 02 65750482 Email: [email protected]


In the fifth century BC, with allied land and sea forces, the two Greek city-states, Athens and Spartan, engaged in a 27 year, three-phased continuous war from 431 BC to 404 BC, the Great Peloponnesian War. The world’s first contemporaneous historian, Thucydides (ca 460 BC – ca 400 BC), wrote a lucid but incomplete account of that conflict ending his narrative in 411 BC. The soldier-historian Xenophon in his memoirs, the Hellenica, completed the history to 404 BC. During the same century, a Chinese soldier and military adviser, Sun Tzu, in ca 473 BC, wrote a handbook of thirteen chapters translated as The Art of War. This highly regarded pamphlet-guide of the stratagems of ancient warfare, yet still pertinent to modern times, Sun Tsu proposed another idea on war:

‘all warfare is based on deception’. (2).

The root of the English word, ‘war’, is the Old High German word, werra, meaning ‘to confound’, curiously resonating the dictum of Sun Tzu. Epidemic is the conjunction of the Greek epi, ‘upon’, ‘near’ and demos, ‘people’, and signifies a disease concurrently affecting a large number of people. Heraclides of Tarentum (Taranto in Southern Italy) ca 70 BC, wrote a book entitled The Soldier, although a recipe collection of plants and drugs, it was the first treatise devoted to modern military medicine.

Kohn itemised some 2,000 wars, revolutions, rebellions and pacifications during the last four thousand years in his Dictionary of Wars (3) and in the six decades since World War II (1939-45), there have been no less than 350 wars, revolutions and coup d’etat throughout the world (4). Mankind’s urge and willingness to wage war may be a species specific characteristic of homo sapiens. The extent and severity of bad outcomes upon the combatant and non-combatant cohorts, so-called ‘collateral damage’, within the warfare of modernity were realised late in the historiography of war. The devastatingly brutal day-long battle around the village of Solferino, Northern Italy, in 1859, between France and Austria, provoked widespread controversy throughout Europe. Five years later the foundation of the Red Cross and the establishment of codified laws of modern war occurred in Geneva. Ultimately four principles were approved as the so-called Geneva Conventions in 1949, and with the

History

War and Disease: War Epidemics in the Nineteenth and Twentieth CenturiesAVM Bruce Short AM RFD FRACP (rtd)

Air Vice Marshal Bruce Short, a retired physician, sometime Surgeon General ADF and editorial consultant to ADF Health, is currently undertaking studies for a Master of Arts (History).

IntroductionWar begets disease, particularly epidemic disease, and these two ancient human disasters remain immutably linked even as the twenty-first century unfolds. This paper will explore the disease and warfare dyad, describe the underlying mechanisms linking the two, provide narratives of significant nineteenth and twentieth century war epidemics, and discuss some bioterrorism-linked diseases.

The Prussian soldier, writer and philosopher, Carl Marie von Clausewitz (1780 – 1831) published a magnum opus entitled Vom Kriege, On War. In this posthumous 1832 publication, the first modern treatise on the philosophy and science of warfare, Clausewitz defined war simply as:

‘an act of violence intended to compel our opponent to fulfil our will’.(1)

Two motives lead men to War: instinctive hostility and hostile intent.

The political objective is the original motive of War.

Vom Kriege, Carl Marie von Clausewitz, 1832


addition of two Geneva Protocols later in 1977, provided the extant legal framework for the humanitarian operation of war.

Nineteenth and Twentieth Century War EpidemicsA seminal manuscript, entitled Epidemics Resulting from Wars, appeared during World War I in 1916 authored by German physician and statistician, Friedrich Prinzing (5). Prinzing coined a special term, ‘war pestilences’, which he reserved for: ‘those infectious diseases which in the course of centuries have usually followed at the heels of belligerent armies’. He ascribed six pestilences: cholera, dysentery, plague, smallpox, typhoid fever and (louse-borne) typhus. He later added scurvy as a seventh ‘war pestilence’. He further acknowledged, ‘as playing an important role in many wars, malaria, influenza, measles, louse-borne relapsing fever and yellow fever’.

Combatants during twentieth century armed conflicts benefited from improvements to military health care delivery such as antibiotic drug therapy, immunisation schedules, anti-malarial drugs and vector control programs, military medicine and nursing, emergency resuscitation and trauma surgical techniques and many more. Prior to the twentieth century, deaths from diseases regularly exceeded other war-caused mortality. During the Napoleonic Wars the British Army suffered seven disease-related deaths for every one combat-related death. Infectious diseases have been the commonest cause of non-combatant morbidity and mortality whilst dermatoses and dental infections together cause the majority of non-combatant morbidity particularly in contemporary military deployments to tropical and warm climate areas. There is, however, one extraordinary exception: during the 1870-71 Franco-Prussian War. As a result of highly effective sanitary reforms within the army, Prussian forces suffered a greater loss of life from combat than due to infectious disease (6).

During the four month-old Spanish-American War (1898) typhoid fever accounted for 87 per cent of the total deaths from disease occurring in the assembly camps. With an overall mortality of 7.7 per cent, typhoid was the major killer of American soldiers during that conflict (7). During the Great War (1914-18), as a consequence to the development of more lethal weaponry and improvements in military medical hygiene, technologies and resources, the trend was reversed whereby the number of deaths from hostilities exceeded those from disease.

Civilian deaths in war include the effects of mass population migration and refugee movements, besieged incarcerations, concentration camp internments, war-related nutritional deprivation and famine, destruction of health infrastructure as well as the dislocation of disease-control programmes. Communicable diseases brought to the civil populace by war fugitives, prisoners of war and demobilised soldiery add to civilian death rates, whilst the disruption of wild-life habitats allows the spread of zoonotic diseases to civilians (8). From the Carnegie Endowment for International Peace, John Bates Clark, signalled during World War I that: ‘the most serious human cost of war has been not losses in the field nor even the losses from disease in the armies, but the losses from epidemics disseminated among civil populations’ (9).

The greatest war-related epidemic in history, impacting multinational citizenry globally, was the influenza A H1N1 virus infection responsible for a three-waved pandemic from March 1918. Including the approximations for Indian cases, the so-called ‘Spanish Flu’ is estimated to have been responsible for the deaths of between 40 to 50 million people, principally in previous healthy young persons (10). The term influenza (or the grippe) is derived from Italian medical writings of the 16th century which attributed the disease to the ‘occult influence of heaven’. J S Oxford et al recently hypothesised that the pandemic commenced in the large British base camp at Etaples in Northern France during the winter of 1917 by linking over-crowding in the many large camp hospitals with, the putative sources of the virus, the camp piggeries and live geese, duck and chicken markets in nearby townships (11, 12).

The Crimean War (1853-6) was the first major war for which there are official summary data on cause-specific losses during the entire period of hostilities and for which statistical analysis can be attempted. The British Army at the Crimean peninsula were subjected to major outbreaks of several diseases, principally cholera, which incidentally also caused the death, in June 1855, of the British Commander-in-Chief, Field Marshal Lord Raglan (1788 – 1855) (13).

Within military populations over the centuries it is possible to identify several recurring aetiological mechanisms to conjunct war with infectious diseases. In the American Civil War (1861-5), multi-centred military mobilization at the commencement of hostilities and surge recruitment programs during protracted campaigns, were commonly complicated by the out-break of so-called ‘eruptive fevers’. These primarily were measles, as well as smallpox, scarlet fever and erysipelas. These epidemics were the consequences of non-immune young recruits from rural areas contacting disease carriers from more urbanised areas. In particular, black troops sustained three times a higher death rate than white recruits when infected by ‘camp’ measles (14). Camp epidemics regularly attended the habitation of large temporary and makeshift cantonments. Historically sexually transmitted diseases have plagued both the garrisoned and active-duty armies and navies of all nations. The incidence of venereal disease, for example, in the British Army during the mid-1800s was variously reported at a steady thirty-five per cent. This high attack rate so impaired force efficiencies that specific legislations, the Contagious Diseases Act regulating prostitution, were enacted in 1864, 1866 and 1869, leading later to protracted public controversy.

Infectious Disease and Contemporary WarfareThe effect of war in promoting the emergence of new disease and the re-emerging of established diseases is well exemplified in modern times with the development of chloroquine-resistant falciparum malaria and insecticide-resistant fleas, the plague vector, during the Vietnam War (1964-73). The Korean Police Action (1950-3) witnessed the emergence of Japanese encephalitis virus and Hantavirus infections both due to the contact of at-risk soldiery and the ecological changes wrought by warfare. Hantavirus diseases also dramatically reappeared during the Bosnian Civil War (1992-5) via the same mechanism. Another example of the human invasions of an ecological jungle niche occurred in World War II with


the widespread outbreak of scrub typhus during the prolonged Burma campaign.

Likely infectious diseases associated with bioterrorism has moved ahead of the American 1942 report by Rosebury and Kabat which listed thirty-three candidate pathogens for analysis as effective biological warfare agents. That report ranked bacillus anthracis in its dormant spore as overall the most important agent (15). The Centres for Disease Control and Prevention (CDC), the United States federal monitoring organisation based in Atlanta, Georgia, functions as the epidemiological eye of the American Public Health system. It has ranked biological agents into three classes based on the dangers they pose. In 2005, the following diseases were classified by the CDC as Class A (easily disseminated and/or highly infectious associated with high mortality rates): anthrax, smallpox, Ebola virus, Francisella tularensis, Yersinia pestis and Clostridium botulinum. However, genetic engineered pathogenic micro-organisms for malevolent purposes are now an entirely practical development. Synthesised in Bio-safety Level 4 laboratories, scientists have developed a recombinant chimera of the Ebola and smallpox genomes. This ebolapox hybrid would result in severe haemorrhagic pustulation leading to body-wide surface blackness, ‘blackpox’, combined with the violent haemorrhaging characteristic of the Ebola virus. The severe haemorrhaging combined with the contagiousness of the smallpox virus can result in near-one hundred per cent fatality rates (16).

The nexus of war and epidemics, the so-called ‘war-and-epidemics couplet’, may not, in the view of Roger Cooter (17), have a certain straight forward relationship. He argues that most epidemics are not rooted in war suggesting, for example, that polio, tuberculosis, whooping cough, scarlet fever and diphtheria correlate poorly with war. Exceptionally, wars have occurred without epidemics. Cooter quotes Creighton’s 1891 article A History of Epidemics in Great Britain, that during the Napoleonic Wars, typhus and other contagious disease became singularly absent from England (18). Further, although smallpox is often linked with war, it has not always been spread by it. An 1882 article by W Guy records that it is in the years of peace that the highest average death-rate by smallpox occurs (19).

Over the last few decades wars have continued to increase in number and increasingly have occurred within poor states. In the past decade poor nations, such as Afghanistan, Bougainville, the Caucasus, Cambodia, the Congo, Rwanda, Somalia, Sierra Leone, Solomon Islands, Sri Lanka and Timor Leste, to mention some, have suffered war. The authors of ‘War Epidemics’ outline three new themes that characterise modern conflicts. The increasing involvement of non-state organisations, with guerrillas, terrorists and rebels ranking as the principal combatants. With non-state participants there has been an associated rise in so-called ‘low-intensity conflicts’ such as counter-insurgencies (El Salvador) and pro-insurgencies (Angola, Nicaragua). Finally, civilians are intermingling with combatants and civilians are now viewed as legitimate targets (the Rwandan genocide) (20).

Interspersed with the epidemic adverse health outcomes from the recent major wars in Afghanistan, Iraq and Kosovo are

the attendant health fall-outs associated with the continued threat of the use of biological agents and weaponry, world energy shortages and world climate change. War between John Keegan’s ‘have-nots’ against the ‘haves’, and vice versa, and increasingly by the poor alone, (21) will underpin and continue to drive the world’s apparent infatuation with military conflict.

Referencesvon Clausewitz, C M, On War, Penguin Press, London, 1968, p. 1011.

Sun Tzu, The Art of War, Barnes and Noble Classics, New York, 2. 2003, p. 9

Kohn G C, Dictionary of Wars, Checkmark, New York, 1999, pp. 3. 557 -594

Smallman-Raynor M R and Cliff A D, Impact of Infectious Diseases 4. on War, Infectious Diseases Clinic of North America, W B Saunders and Co, June 2004, 18: 2, p. 20

Smallman-Raynor M R and Cliff A D, War Epidemics: An Historical 5. Geography of Infectious Diseases in Military Conflicts and Civil Strife 1850 – 2000, Oxford University Press, Oxford, 2004, p. 35

Short, B H, Bioterrorism: The Menace of Microbiological Science, 6. United Service, Journal of the Royal United Services Institute of NSW, 2008, 59: 3, p. 12.

Cirillo V J, Fever and Reform: The Typhoid Epidemic in the Spanish-7. American War, J History of Medicine, 2000, 55, p 363.

Smallman-Raynor M R and Cliff AD, War Epidemics, 8. op cit., p. 40

Smallman-Raynor M R and Cliff A D, Impact of Infectious Diseases 9. on War, op cit., p. 7

Bartlett J and Hayden F, Influeza A (H5N1): Will it be the next 10. Pandemic Influenza? Annals of Internal Medicine, 2005, 143: 6, pp. 460-1

Oxford J S, Lambkin R, Sefton A et al, A Hypothesis: the conjunction 11. of soldiers, gas, pigs, ducks, geese and horses in Northern France during the Great War provided the conditions for the emergence of the ‘Spanish’ Influenza Pandemic of 1918-1919, Vaccine, 2005, 23. p. 940

Oxford J S, Lambkin R, Sefton A et al, World War I may have allowed 12. the emergence of ‘Spanish Influenza’, The Lancet, Infectious Diseases, 2002, 2, p 111-14

Hibbert C, The Destruction of Lord Raglan: A Tragedy of the 13. Crimean War, 1854-5, Penguin, London, 1963, pp. 338-9

Smallman-Raynor M R Cliff A D, Impact of Infectious Diseases on 14. War, op cit., pp. 8-9

Short B H, Bioterrorism: The Menace of Microbiological Science, 15. op cit., p. 14

Zubay G et al, Agents of Bioterrorism: Pathogens and their 16. Weaponisation, Columbia University Press, New York, 2005, pp. 73-6

Cooter R, Of War and Epidemics: Unnatural Couplings, Problematic 17. Conceptions, J Society for the Social History of Medicine, 2003, 16: 2, pp. 285-6

Creighton C, A History of Epidemics in Great Britain, (1891) London, 18. reprinted 1965, vol II, pp. 163-7

Guy W, The Small Pox Epidemic as Affected by the States of War and 19. Peace, J of Statistical Society, 1882, 45, 576-87, p. 584

Smallman-Raynor M R and Cliff A D, War Epidemics, 20. op cit., pp. 691-3

Keegan J, A History of Warfare, Pimlico, London, 1994, p. 5721.


but also of the Hutu majority and even the pygmy Twa. He finally deals with the post-genocide chaos of displaced persons (DP). One such DP camp was a non-government organisation-financed sanctuary in south-western Rwanda structured around the Catholic Church at Kibeho.

In a sudden forty-eight hour frenzy of homicide, on the 20th April 1995 the Tutsi-dominated Rwandan army, the Rwandan Patriotic Army (RPA), unleashed the slaughter of a conservatively estimated 4,000 Hutus within and around the camp at Kibeho. To become known as the Kibeho Massacre. In this diabolic arena of death facing more than 2,000 heavily armed RPA were seven members of a tri-service ADF medical

Book Review

Aftermath of the Rwandan Genocide“Pure Massacre: Aussie Soldiers Reflect on the Rwandan Genocide”.Kevin O’Halloran, Blue Sky Publishing, Newport, NSW, Australia, 2010. ISBN: 9780980325188. pp. 279, (rrp. $34.99).

AVM Bruce Short AM RFD FRACP (rtd)

Good Men Do Nothing

The subject of this book, the 1994 Rwandan Genocide and one of the aftermaths, the Kibeho Displaced Persons’ Camp massacre in April 1995, may not at first appeal to the general reader. The year 1995 was the 50th anniversary celebration of the UN, whilst 2010 is the 15th anniversary of Australia’s UN operation in Rwanda. Kevin “Irish” O’Halloran, a platoon sergeant at the time, records his thoughts and reactions of the second half of the twelve month Australian Defence Force (ADF) commitment to the United Nations Assistance Mission for Rwanda (UNAMIR).

The 1994 Rwandan genocide cost between 800,000 and 1,000,000 lives, of all ages, in a little over one hundred days. This is a rate of 8,000 to 10,000 individually killed each day, every day.

A foreword is provided by the former Canadian UN Force Commander UNAMIR II, Major General Guy Tousignant, “what distinguishes Rwanda from other UN peacekeeping missions is the failure of UNAMIR I to protect victims of the genocide, and that ought to be the principal humanitarian failure worth remembering about Rwanda.”

O’Halloran provides a well researched historical background to the United Nations and to the mandate or UN Security Council Resolution establishing UNAMIR. He skilfully describes the administrative nightmare consequent to the Security Council’s refusal to move from a peacekeeping mandate of Chapter VI to the more appropriate for UNAMIR, the peace-enforcement Chapter VII. This perverse UN decision was to put UNAMIR’s ‘blue-helmeted’ troops in even more danger than normal deployments.

He informs the reader of the history of the chronic Tutsi-Hutu ethnic divide. He details the 1990 Rwandan Civil War, the signing of the Arusha Accord in 1993, the April 1994 genocide followed by one hundred days of slaughter mainly of Tutsi

team and a platoon of lightly-armed ADF infantry support. These members of the Australian Medical Support Force and the security support, Australian Services Contingent, were part of the 300-strong ADF contingent to Rwanda, mounted as Operation TAMAR. But the UN mandate determining UNAMIR II prohibited soldiers using their weapons, except in self-defence, nor to assist the natives they were sent to protect. “They were forced to watch as thousands died”. However, under fire these courageous few did rescue, treat and succour many of the injured Rwandans.

The author devotes several passages at the end of chapters to what he titles ‘Australian Soldiers Reflect’. The soldier’s accounts are moving, compassionate, angry, fearful and horrific. All their emotions may be summed up mainly as a reaction to the perception of the UN as “good men do nothing”. He also includes harrowing survivor stories.

The soft-covered book is well illustrated with sensitively but well chosen colour-plates and includes a Rwandan roll of the Australian Service Contingent I and II, a resume of the ADF honours and awards for recognised gallant service, a useful glossary of military terms and abbreviations, and a small but handy index. Belatedly and curiously, ADF personnel had to wait some years before UNAMIR II service was recognised as eligibility for the Australian Active Service Medal (AASM).

Could the UN return to Rwanda? Paul Kagame, a major general with the Tutsi rebel movement, the Rwandan Patriotic Front (RPF), crossed over from Uganda in 1990 commencing the

Rwandan civil war. Kagame, after serving the last ten years in the top post, was re-elected as the Rwandan president in August 2010. In the same month the UN High Commissioner for Human Rights completed an extensive investigation accusing Rwanda of “wholesale war crimes, including possibly genocide”. These followed Rwandan incursions into the neighbouring Democratic Republic of Congo during the past seven years. If genocide is proven, will the UN next time be seen as ‘good men properly doing the right thing.’?

This manuscript has special appeal to those with Rwandan service, including their families, but should be read by all ADF personnel, particularly those who are deployable. The interested general reader, military, political and genocide historian will find the oral testimonies revealing, persuasive and informative.

Will there be further genocide to add to the litany of the generally recognised twentieth-century African genocides? The genocide of the Herero and Namas in German South West Africa (1904 – 08), Hutu-Tutsi in Burundi (1972), the Horn of Africa genocides (Ethiopia, Eritrea, Somalia and Sudan) in the 1960s to the1980s, Rwanda (1994) and since February 2003, in Darfur in Western Sudan. Genocide within Africa unfortunately remains very topical. I earnestly recommend Kevin O’Halloran’s candid, researched and well-written documentary.

The book contains numerous coloured plates and was published in 2010 as a soft-cover indexed edition of 279 pages. n


AbstractMild hypothermia increases morbidity and mortality in •trauma patients and battle casualties.

Physiological responses to hypothermia can be harmful.•

Measurement of core temperature without measuring limb •temperature, leads to under-detection of hypothermia.

Understanding the mechanisms of heat loss allows us to •develop effective strategies to prevent minimize and treat hypothermia.

Simple preventative measures in the field can prevent or •minimize its occurrence.

Where possible hypothermia should be treated aggressively •by active warming as early as possible.

Recently developed devices make this possible. •

IntroductionMild hypothermia (a drop of core temperature of 1°-3°C) is potentially harmful, or can even prove fatal, for battle casualties. Hypothermia is not confined to cold climates. It can occur in temperate and even sub tropical climates¹ and is endemic in air conditioned hospitals.2

While there has been a traditional belief in the military that hypothermia is beneficial to the battle casualty, this is not the case. In the 19th century it was believed that casualties who suffered severe hypothermia lost less blood.3 Even in the Falkland’s war there were reports that severe hypothermia was life saving. Close examination has shown this to be taken out of context.4

Mild hypothermia is associated with impaired immunity, increased wound infections, delayed wound healing, coagulopathy, increased requirement for blood transfusion, and post-operative cardiac events, such as myocardial infarction and severe arrhythmias.5,6,7

Controversy remains over the optimal management of the head injured patient. While it is known that patients who fail to regain consciousness following medical cardiac arrest benefit from induced moderate hypothermia, at present it is regarded

Hypothermia

Mild hypothermia in the battle casualtyMAJ Kenneth J. Wishaw

Major Ken Wishaw is a reserve anaesthetist with the 2nd Health Support Battalion, Enoggera. He deployed to Afghanistan in 2009. He was previously in the RAAF Reserve prior to 1992. He has been an instructor on the Royal Australasian College of Surgeons course, Early Management of Severe Trauma, and an instructor at the Sydney and Brisbane Medical Simulator Centres. He co-founded CareFlight (Sydney) and the New South Wales Medical Retrieval Service. His civilian practice is on the Sunshine Coast, Queensland.


that while hypothermia may be beneficial to the brain, the complications of hypothermia in the injured patient outweigh any benefits.8 This is the subject of further study.

Hypothermia in trauma is now regarded as part of the lethal triad along with coagulopathy and metabolic acidosis. Rapid reversal of acidosis, early use of blood products and aggressive management of hypothermia, decreased trauma mortality in Iraq from 65% to 19% in one study.9 The Australian military experience in Afghanistan with this method of resuscitation has also been positive.10

The Queensland Trauma Registry Study demonstrated that a drop of core temperature of 2°C quadrupled the fatality rate in severely injured patients. Patients who arrived normothermic but became hypothermic in hospital were 2.5 times more likely to die than those kept normothermic.1 Severe hypothermia (a drop of core temperature of greater than 5° C) in association with severe injury has close to a 100% mortality rate.

How does hypothermia occur?Understanding the physics and the physiology of heat loss and hypothermia is the basis of effective strategies. Heat is lost by three mechanisms; radiation, convection and conduction. i) Radiation heat loss is to cool objects that are not in contact with the body. Heat loss from an exposed patient to cool surroundings is proportional to the fourth power of the temperature difference between the two.5 Therefore slight decreases in environmental temperature lead to big increases in heat loss. Conversely warm environments dramatically slow heat loss. ii) Convective heat loss is due to air movement over the body. While still or entrapped air is an effective insulator, evaporation of sweat in moving air is an effective cooling mechanism, even if air temperature exceeds body temperature. Air movement over wet clothing leads to significant heat loss. iii) Conductive heat loss occurs to cold objects in contact with the body and is proportional to the area of contact, the temperature difference and the thermal conductivity of the material (Fourier’s Law).

Physiological response to hypothermiaThere are four major physiological responses to hypothermia; all of which have undesirable side effects in the injured patient. These are vasoconstriction, shivering, behavioural mechanisms and countercurrent mechanism.

i) Vasoconstriction. Decreased skin blood flow insulates the body core from a low temperature environment. This however slows heat from external body warming being transported to the inner core of the body. Core rewarming by external heating techniques can be delayed by several hours once skin vasoconstriction has been established. The decreased skin blood flow is also considered to be a major factor in delaying wound healing and the incidence of wound infections. This situation is exacerbated in the hypovolaemic patient, who peripherally vasoconstricts to maximize blood flow to essential organs. It is important to note that in order to preserve brain temperature the scalp and forehead do not vasoconstrict in cold environments. This is why exposure of the head and neck to cold environments has a dramatic cooling effect and should be prevented wherever possible in casualties. It is also why forehead temperature correlates well with core temperature,

and is a reasonably accurate way of non-invasively assessing core temperature in certain conditions.

ii) Shivering. This may triple metabolic heat generation but also increases oxygen consumption. In trauma patients where oxygenation may be marginal, this is highly undesirable.

iii) Behavioural mechanisms. Humans are highly dependent on behavioral changes (such as seeking shelter and adding warm clothing) to stay warm in cold environments. As a patient, the ability to don extra clothing or change the environment is limited or impossible. The patient becomes totally reliant on their caring staff to make the necessary changes. Too often fully clothed (particularly those in theatre gowns), active staff overlook the needs of the partially naked and inactive patient. Heightened awareness of this is essential for all staff.

iv) Countercurrent mechanism. The major proximal limb blood vessels run adjacent to each other in a common sheath. This allows warm arterial blood to transfer its heat to cool venous blood. The net effect is to maintain warmth in the core by sacrificing limb heating. Hypothermia therefore has two stages. Firstly there is a loss in limb heat and a fall in limb temperature, while core temperature and heat is preserved. If the four physiological defenses are inadequate, core temperature will then start to drop. Severe heat loss may occur before the core temperature drops. For example, it is common for frostbite cases to have a normal core temperature. If we rely purely on core temperature to asses heat loss, we will not detect the peripheral hypothermia, which may lead to generalized hypothermia. Increasing blood flow through cold limbs, paradoxically, may convert peripheral hypothermia to generalized hypothermia. This occurs following the administration of resuscitation fluids (even if they are warm) or anaesthesia agents (which are all vasodilators). This is known as redistributional hypothermia and occurs within minutes of resuscitation or anaesthesia induction. It has been shown that platelets and white blood cells that traverse a cold limb even when the patient’s core is normothermic, are inhibited,11,12 and may therefore contribute to increased blood loss and increased incidence of infection.

Hypothermia therefore should be avoided where possible by anticipating the problem, and both peripheral and generalized hypothermia treated aggressively.

Prevention and treatment of hypothermiaThere are two key methods commonly used to prevent and treat hypothermia; passive and active. Passive insulation only works to keep warm people from getting cold. The body at rest produces an average of 70 -100 kilocalories (Kcal) of heat per hour (e.g. enough to heat two cups of coffee). If we assume passive insulation is perfect, this amount of heat will raise a 70 kg patient’s temperature by 1°-1.3°C per hour. In reality, insulation from the cold is less than perfect and temperature rise is usually much slower. The use of heated cotton blankets has been shown to have no positive effect on patient re-warming.13 Therefore passive warming is inadequate in managing severe trauma cases.

Active warming can be classified as invasive and non-invasive. Invasive methods includes femoro-femoro bypass therapy and more recently the use of femoral central lines incorporating

balloons flushed with hot saline.14 At present they are not logistically appropriate for consideration by the defence force (though this may rapidly change). Non-invasive warming devices include warm air blankets, electrical warming mattresses and foil blankets incorporating chemical heat packs. Their role in hypothermia prevention and treatment is discussed below.

Practical strategies for avoiding or treating mild to moderate hypothermia in battle casualtiesHypothermia avoidance and treatment is not difficult, and is largely a combination of awareness and common sense. These are suggestions only and must be viewed in the light of the strategic and tactical situation. They should be considered by all clinical staff in cold, temperate, sub-tropical and air conditioned environments. The likelihood of hypothermia in battle casualties should be anticipated and prepared for, prior to any field operation.

Pre-hospitalSimple measures at this stage can prevent the problem before it occurs, which is far preferable to treating hypothermia after it is established. This can be life saving. Formal temperature measurement in this environment is both difficult and probably unnecessary as simply feeling the patient and considering the situation and environment will determine whether anti-hypothermia measures are required.

As soon as possible, casualties should be removed from cold, wet, and windy environments. Any wet clothing should

be replaced with dry clothing, even thought this means temporarily exposing the patient to the elements. Where possible the head and neck should be covered by using towels, beanies, or balaclavas. Cover with blankets as available and do not expose the patient unnecessarily.

If the casualty is lying on cold ground, place them on insulating material, such as a bed roll or sleeping bag. Canvas litters or stretchers, do not have the insulating qualities of proper mattresses, so placing a bed roll or sleeping bag underneath the stretcher (where body weight will not compress it), or even taping a foil blanket to the underside of the stretcher should further decrease radiation heat loss. This warrants extra study.

Where active heating devices are available, these should be instituted as early as possible. These may include foil blankets incorporating chemical heat packs, or battery operated clinical warming blankets. Ad-hoc active warming with non medical heat sources has great potential for causing burns. Infusing one litre of intravenous fluid at 20°C or one unit of blood at 4° C will drop mean body temperature by about 0.25°C, therefore IV fluids should be warmed, and equipment to do this in the field (Thermal Angel) is now available in the Australian Defence Force.

In hospitalThe resuscitation room should be warmed prior to casualty arrival to 25°C-30°C. The colder the patient is likely to be, the warmer the room temperature. Casualties should be fully


undressed for initial assessment and resuscitative procedures, and then covered as much as possible.

Core temperature should be recorded by the most accurate means possible. Ideally this should be by mid-oesophageal measurement. If this is not possible, rectal, axillary or oral temperature is preferable over ear canal measurements, which have been shown to be convenient but less accurate.15 Limb temperature can be assessed by simply feeling the limbs or by using infra-red reflectance thermometers. Unfortunately the most accurate skin thermometer, for assessing deep tissue temperature, is only available in Japan.16

If either peripheral or generalized hypothermia is present, active warming by the use of warm air blankets and warming mattresses should be instituted, aiming to have both core and limb temperatures above 36°C. Warm air blankets are the mainstay of non invasive active patient warming. Reliability of these devices can be affected in the dusty military environment unless regular preventative maintenance is undertaken. The combination of a medical warming mattress and warm air blankets is far more effective in rapid rewarming than warm air blankets alone.17 While there have been cases of patient burns by warming mattresses in the past, these may have been due to the fact that they were used as the sole heating source and/or technical faults. Present technology mattresses have been shown to be safe.18 Battery powered medical warming mattresses are now available.

Most intravenous fluid warmers (including the Thermal Angel) are only effective up to flow rates of 150 mls/min. This is inadequate for in-hospital battle casualty resuscitation. High volume warmer infusors capable of warming fluids at flow rates up to 700 mls/min should be utilized.

Operating theatreAll the above actions need to continue in the operating theatre. Maintaining such high temperatures can be a challenge for scrub staff, but are warranted. The wearing of ice vests by scrub staff has been shown to be useful. All irrigation fluids need to be warmed. The theatre table should also be pre-warmed and or utilize a warming mattress. “Gel” mattresses and pads have a high thermal conductivity and great potential to drain body heat. They should be pre-warmed.

Surgery should be abandoned as soon as possible if an increasing core and limb temperature is not achievable (i.e. Damage Control Surgical principles).Postoperatively, temperature monitoring must continue. Ward temperature must be dictated by the needs of the patient rather than the comfort of the staff.

ConclusionMild hypothermia is harmful to battle casualties. Prevention is better than cure and the earlier it is managed, the better. It is easily overlooked in countries, such as Australia, that are largely temperate and sub tropical, and it occurs far more commonly than is realized. Current thinking is that definitive treatment should be both aggressive and by active means, but simple preventative strategies in the field can also have dramatic effects on casualty outcomes through less blood loss, less infections and less cardiac complications.

Conflict of InterestI have no financial affiliation, agreements present or pending, nor have I ever received any financial benefit from any of the product manufacturers or retailers of the products reviewed.

ReferencesAi1. tkena, LM, Hendrikzc, JK, Dulhuntyd, JM & Rudd, MJ. Hypothermia and associated outcomes in seriously injured trauma patients in a predominantly sub-tropical climate, Resuscitation, 2009; 80: 217–223.

Forbes, S, Eskicioglu, C, Nathens, A, Fenech, D, Laflamme, C, 2. McLean, R & McLeod, R. Evidence based guidelines for prevention of peri-operative hypothermia, Journal of the American College of Surgeons, 2009; 209: 492-503.

Arbinson, MJH. William Harvey, hypothermia and battle injuries, 3. British Medical Journal, (letter), 1999: 319: 1561.

Smith, J Surgeon Commander. Commentary on military cold injury, 4. Journal Army Medical Corps, 1984; 130: 89-96.

Buggy, DJ & Crossley, AWA. Thermoregulation, mild peri-operative 5. hypothermia and post anaesthetic shivering. Review Article. British Journal of Anaesthesia, 2000; 84: 615-628.

Sessler, DI. Temperature monitoring, In: 6. Anesthesia, 3rd edition. Edited by RD Miller. New York, Churchill Livingstone, 1990:1227-1242.

Sessler, DI. Complications and treatment of mild hypothermia. 7. Review Article. Anesthesiology, 2001: 95: 531-543.

Neuhaus, S, Wishaw K, & Lelkens C. Australian experience with 8. frozen blood products on military operations, Medical Journal of Australia, 2010; 192: 203-205.

Sydenham E, Roberts I, Alderson P. Hypothermia for traumatic 9. head injury, Cochrane review http://www2.cochrane.org/reviews/en/ab001048.html

Holcomb, J. Damage Control Resuscitation. A commentary. In: 10. War Surgery in Afghanistan and Iraq. A series of cases 2003 – 2007. (Eds) S Nessen, D Lounsbury & S Hetz. Washington DC, Office of the Surgeon General, 2008:49 – 51.

Romlin, B, Petruson, K. & Nilsson, K. Moderate superficial 11. hypothermia prolongs bleeding time in humans, Acta Anaesthesiology Scandinavia, 2007; 51:198–201.

Watts, DD, Trask, A, Soeken, K, Perdue, P, Dols, S, & Kaufmann, 12. C. Hypothermic coagulopathy in trauma: effect of varying levels of hypothermia on enzyme speed, platelet function, and fibrinolytic activity, The Journal of Trauma: Injury Infection, and Critical Care, 1998; 44:846-854.

Sessler, DI. Heat loss in humans covered with cotton hospital blankets, 13. Anesthesia and Analgesia, 1993; 77: 73-77.

See 14. http://www.zoll.com/medical-technology/temperature-management/

Sessler, DI. Temperature monitoring and peri-operative 15. thermoregulation, Anesthesiology, 2008; 109:318-338.

Matsukawa T, Kashimoto, S Ozaki, M. Shindo, S & Kumazawa, T. 16. Temperature measured by a deep body thermometer (Coretemp®) compared with tissue temperatures measured at various depths using needles placed into the sole of the foot, European Journal of Anaesthesiology, 1996; 13: 340-345.

Dawes, R, Rhys Thomas, G.O. Battlefield resuscitation, Current 17. Opinion in Critical Care 2009; 15:000-000

Baker, EA & Leaper, DJ. Pressure-relieving properties of an intra-18. operative warming device, Journal of Wound Care, 2003; 12: 156- 160.

Kenneth J. Wishaw

6 Crystal Waves Place Alexandra Headland, Queensland 4572

Mob 0412 947 429 Fax 07 5475 4949

[email protected]


Of times past:

When you’re wounded and left on the Afghanistan plain

And the women come out to cut out what remains.

Just roll on your rifle an’ blow out your brains

An’ go to your God like a soldier.

– Rudyard Kipling

Of times present:

The improvised explosive device (IED) produces the most devastating complex tissue injury that contemporary military surgical teams have to deal with1-2. It is the signature form of wounding of present day Australian and Coalition service personnel3. A system of care that can deal with these injuries will, by definition, be capable of dealing with a wide range of other injuries. This system must also be able to deal with civilian injury and illness- both adult and paediatric- that will be unavoidable in conflict. There is a readily accepted moral and humanitarian responsibility to be prepared to treat such casualties.

The whole tenet of asymmetric warfare is to damage morale and mission by sudden brutal demoralizing strike in a political environment in which the loss of life of the military personnel carries sensitive consequence. Protection by warfare means have been developed (fighting doctrine, personal protection, offensive and defensive technology). The principle lesson of the present time is that health protection by means of appropriately equipped hospitals, with appropriately trained staff can be developed to meet this threat, but they require a depth of resource and skills available to manage such wounding4.

Care of the combat wounded involves many in the battle space, and with varying degrees of sophistication. Modern treatment dictates actions by all involved from the point of wounding through to sophisticated transfer out of the Area of Operations. This paradigm is illustrated in Figure 1 (next page).

Case Study

Management of IED Injury:A Case Reflective of Contemporary Treatment and Understanding of Resources Required to Save LifeCOL Andrew M. Ellis OAM RAAMC FRACS (Orth) FAOrthA Senior Health Advisor 2DIV LTCOL Fran Smith RAAMC FRACP FANZCA FCICM Standby Reserve

Drs Smith and Ellis were respectively the Anaesthetist/Intensivist and Orthopaedic Surgeon/Clinical Director AUS MTF 1 Tarin Kowt Afghanistan 2008.

LT COL Fran Smith is presently a VMO in Anaesthesia at Liverpool Hospital and VMO in ICU at Bankstown Hospital. She joined the Army Reserve in 1999 and has had deployments to the Solomon Islands, Bougainville, Banda Aceh and Afghanistan. She was the Foundation Medical director of CareFlight/NSW Medical Retrieval Service and worked as a Retrieval specialist for seven years. She was an EMST Instructor from 1992 until 2005.

COL Andrew Ellis is posted as the Senior Health Advisor 2 DIV. He is a VMO Orthopaedic Surgeon at Royal North Shore Hospital Sydney, with an interest in trauma, arthroplasty and the management of the orthopaedic consequence of neurological disorders. For some years he has directed ADF Early Management of Severe Trauma (EMST) courses, the military module thereof and instructed on the Military Module of the Definitive Surgery of Trauma Course (DSTC). He is a widely deployed and experienced army orthopaedic surgeon.


All stages of the system need to be in place to ensure the optimal care of the combat wounded. It must be acknowledged, right from the start, that the provision of the system of combat casualty care is expensive, people and resource intensive and requires robust, flexible and responsive logistic support. Resuscitation, Surgery and Intensive Care must be proximate, and varying types of aeromedical evacuation must be available in a timely manner to transport casualties between various levels of care, including intercontinental4 .The very size and complexity may well mean it is likely beyond the capability of one national military element to provide it or sustain it totally, and that it will most often be achieved by collective effort of a coalition of partner nations.

Using such systems of care has yielded results4-6. The risk of death from military wounding has never been lower and more severely injured are surviving, with wounds that were likely fatal in previous conflicts 4,6.

The authors present a case of severe wounding which is illustrative both of the comprehensive system of care and the cooperation of various coalition health assets to achieve survival in an otherwise extremely severe combination of injuries. This patient, with traumatic below limb partial amputations and pelvic fracture, nearly died from hypovolaemaeic shock. Cold and acidotic he experienced a severe coagulopathy which complicated these injuries. Using contemporary techniques life was saved and the patient returned to his home country (Holland) and made a documented good physical recovery.

WoundingTowards the end of its mission in Afghanistan in April 2008 the 10 person Australian Surgical Team (AUS MTF1) had been relieved in place in the Dutch-Australian Role 2E Hospital Camp Holland, Oruzgan Province.

At this time notification was received that 3 urgent surgical cases were expected from an IED strike against a coalition vehicle convoy. It eventuated that two of the patients had minor injuries. The driver was more severely injured, and is the centre of this discussion.

Commentary:

Pre-hospital care has improved, especially with the routine use of pressure bandages, haemostatic agents and combat tourniquets6 . The doctrine of Tactical Combat Casualty Care (TCCC)6, 7, known in Australia as Care of the Battle Casualty, is well rehearsed amongst soldiers and widely practiced.

In this scenario the receiving medical teams really have a very wide expectation of numbers of casualties and type of injury. There is a realisation that information provided in a NATO Nine Liner CASEVAC is provided in the heat of battle and can vary in accuracy...all the treating team is sure of is to stand by to receive potential seriously injured coalition members.

In the setting of a medium size forward surgical team this will be a challenge. The multiple casualty plan is activated, and three resuscitation teams are stood up- the duty team, the off duty team and a composite team made of the primary health care team staff assemble. Surgical space is cleared, and throughout the hospital teams wait in readiness to receive. All stretcher teams are made ready, the Operating Room (OR) is prepared, and Pathology, Radiology and Intensive Care Unit (ICU) clear all tasks. The Senior Nursing Officer assesses all inpatients for possible ambulatory discharge if necessary.

ResuscitationOn arrival the patient was alive and responding. Pre-hospital care had focussed on physical security of the patient, the application of bilateral tourniquets and rapid evacuation. It was clear that he had suffered very complex lower limb injuries with blood loss, and at this stage extremity bleeding was controlled. Airway and breathing assessment showed he had a clear airway by virtue of his conversation and his trachea was midline, oxygen saturation was 99%. The presence of tympanic membrane rupture was noted. Two above knee tourniquets had been placed and these remained in situ.

The resuscitation team worked around him with a main effort directed at assessing and treating his hypovolamic shock. The initial haemodynamic parameters showed the patient to be in probable Grade 3 shock: blood pressure 90/40 mmHg, PR 120

Figure 1: Levels of Care across the Battlefield.

bpm, pale with capillary return > 2 secs. Warming was begun. The trauma x-ray series was performed, and the pelvis x-ray showed a significant vertical shear fracture of the pelvis. A FAST showed free pelvic fluid. A pelvic binder was applied. Bloods were drawn as baseline studies. At this time the resuscitation was not guided by them, but rather by the obvious injuries suffered and the haemodynamic parameters. Time was not wasted in dressing wounds as he would shortly move to the next room for surgery. It was clear that the tourniquets were effective.

Direct liaison with the pathology technicians alerted them to the need for rapid availability of blood product-including

Figure 2: Complex Lower limb IED Injury

packed cells, fresh frozen plasma and platelets. In this case all blood products where supplied frozen. While there was always a certain amount defrosted, ready for immediate use, it was obvious this supply would soon be exhausted and so staff began the process of defrosting, washing and cross matching more blood. Additional staff was called upon to aid this process.

Commentary:

Control of blood loss remains the highest priority for resuscitation teams, and this is combined with obtaining intravenous access. Large bore peripheral lines will most

Figure 3: Pelvic Sling in situ


often suffice; intra-osseous access is reliable and quick, with an estimation of 95 % success within ninety seconds. Central venous cannulation has a role in experienced hands only and should not delay transfer to the OR.

The understanding of the coagulopathy of severe trauma has been informed by experience in Operations Iraq and Enduring Freedom8, and resuscitation with whole blood, platelets and coagulation factors has led to improvements in the care of coagulopathic wounded4, 7-9. Aggressive warming, restriction of crystalloid, and the doctrine of damage control resuscitation are understood, and part of routine forward care 4,9.

The need for large volumes of blood product is recognised now by the development of massive transfusion protocols, and the ability to switch to these directly in cases of severe wounding has promoted survival in cases of complex, severe military wounding. It has been estimated that up to 7% of battle casualties may require massive transfusion9.

Blast injury contains at least three elements of possible injury: blast overpressure, fragmentation and burn. Other more complex elements in this scenario can include consequent vehicle crash, trapping by compression and secondary attack whilst alighting from the vehicle. The injuries can be complex, with many elements. Traumatic brain injury and mid face injuries are common enough, and can add to the injury severity score10-12.

The suspicion of primary blast injury (with pulmonary and cerebral effect) is highlighted by recognising the mechanism of injury and by the presence of perforated tympanic membranes, though not excluded by absence of the latter10,11. The Resuscitation Team (and later the anaesthetist) should be alert to the potential need for intercostal catheterisation12. CXR is an important adjunct in this assessment.

SurgeryFrom the time of wounding it was clear that this patient would require surgery and as resuscitation continued the Anaesthetist began the process of assessment and consideration for rapid transition to the OR for damage control surgery, and it was becoming clear that the signs of blood loss were ongoing and could not be accounted for by his leg injuries alone.

The anaesthetic pre-operative assessment issues included consideration of timing for intubation. By this time the patient was increasingly shocked with HR of 172 bpm and systolic BP 60mmHg, after an initial bolus of 2 litres of crystalloid. With the patient still talking and without airway issues, intubation is probably best performed at the time of anaesthetic induction, when the surgeons are ready to start operating. All effort is focussed around preventing delay in commencing surgery. In this man, by virtue of his age and service, the absence of co-morbidities was assumed. He was cold, and despite attempts at warming the exposure required to identify injuries, perform x-rays and ultrasound and commence resuscitation had allowed heat loss by evaporation and refraction. Rapid assessment showed this would be an issue. At this time the anaesthetist was also the intensivist and the ICU needed to be made ready, including clearing and preparing a bed.

The Australian surgical team were asked by their Dutch colleagues to help.

Rapidly the three surgeons moved to complete the amputations. Surgical pneumatic tourniquets replaced the combat application ones, and rapid (in this case guillotine) amputations completed.

As the patient remained very unstable, ongoing bleeding into the pelvis was assumed the cause. Angiographic embolisation was not possible in the forward surgical facility and in consultation the surgeons decided stabilisation followed by damage control laparotomy with packing was next. A pelvic fixator was applied rapidly with anterior compression to close the pelvic volume and stabilise the pelvis, but all recognised the limitations of this in a vertical shear fracture. With continuing instability a laparotomy was performed which showed extensive pelvic haematoma. Despite initial packing the pelvic bleeding continued, after discussion the situation was universally concluded to be desperate. As a final surgical intervention the left common iliac artery was ligated, the pelvis repacked and the abdomen left open with drains and negative wound pressure dressing in situ.

The challenges of Anaesthesia for this man were keeping up with blood loss (both observed and unknown), his hypothermia (inadequate temperature monitoring was a challenge), his evolving acidosis and the coagulopathy. Vasoconstrictor (noradrenaline infusion) was commenced at this time. Perioperatively he was transfused 22 units of packed cells, 15 units of fresh Frozen Plasma and 6 units of platelets with a dose of 60 micrograms/kg of Factor VIIa, which in the presence of severe hypothermia and acidosis may not have been effective.

The intraoperative physiological features showed increasing acidosis (Table 1). His coagulopathy is

Figure 4: AP Pelvis x-ray showing vertical shear fracture.

Table 1: Intra-operative Pathology results

illustrated in the Figure 5. In this clinical photograph the observer can note general ooze from every line site, the external fixation pins and even his multiple small facial lacerations.

Commentary:

The understanding of the role of damage control surgery has been informed by wounding in the recent era of operations in Iraq and Afghanistan. The principles of this approach, developed by Rotando13, Schwab14 and Holcomb 15and others are highlighted in figure 6. The key features are very short duration haemostasis surgery, performing only life and

Figure 5: Coagulopathy apparent at the end of surgery.

Figure 6: Key principles of damage control surgery CABC is the philosophy of identifying and treating life threatening circulation (C) problems ahead of airway and breathing issues (ABC).

ADF Health


limb saving surgery with rapid transition to ICU where the physiological derangements associated with such major injury are reversed, and then for more complex surgery to be performed later. These later surgeries may be done by the forward surgical team, so as to allow transfer (“stabilisation”) or later in a more advanced hospital, usually out of the Area of Operations4, 15.

Intensive Care and Preparation for Evacuation.

As day turned to night, following packing of the pelvis and abdomen, the patient arrived in ICU with his abdomen open and obviously coagulopathic. The challenge of blood product transfusion seemed huge and all were aware that surgical options had been exhausted. He continued to bleed. He still seemed volume depleted. He remained on high dose noradrenaline, his temperature was 33.4 oC. His blood pressure was 110/50 mm Hg, and he was tachycardia (110 bpm). Measured urine output was minimal. He remained intubated and sedated on IPPV, 40% FiO2. The Factor VIIa dose was repeated (60microgms/kg) and once again in the presence of hypothermia and acidosis was likely to be ineffective.

The situation looked grim. The surgical team talked despondently of repacking the abdomen if necessary .Physiologically the patient was more acidotic, and despite transfusion and surgery his haemoglobin had fallen to 65 g/L and now measured for the first time, his coagulopathy was significant.

Arrangements were put in place for aeromedical evacuation, his condition from the outset realised to require definitive treatment elsewhere. At this stage the patient was far from stable enough to transfer, and it was uncertain if he would become so. Clearly the focus of the entire medical treatment facility was around his care, with little spare capability if other needs arose.

Over the next 18 hours he was rewarmed but still remained acidotic. (Ph. 7.29, Base Excess –10 mEq/L) and coagulopathic (APTT 63 sec, PT 20 sec, Platelet count 13x10 6 /L). Transfusion of blood and factors continued and Noradrenaline was administered at high dose. The mean arterial pressure stayed at a 75 mmHg and his urine output established and continued at around 70mls/ hour. However his measured blood loss was 300 ml/hr and he remained unfit for flight.

Evacuation to Europe, an expensive resource intensive arrangement and highly

necessary for this patient, was potentially being delayed and possibly turned around. The next course of action was far from clear. Our Australian anaesthetist, a highly experienced intensivist, worked with her Dutch colleague to treat the coagulopathy. More blood components, especially platelets were transfused. Ventilation was adjusted to help mitigate the acidosis. With these measures plus the fact that the patient was no longer hypothermic allowed a more appropriate dose of Factor VIIa (120MCG/kg) to be administered along with Vitamin K. Tranexamic acid was not available. With modern communication the intensivist was able to discuss the actions taken with colleagues in Australia (“phone a friend”).

Within 3 hours he was weaned off Noradrenaline and all bleeding had ceased. Repeat arterial blood gases showed that his coagulopathy and acidosis had been corrected.

A British intensive care retrieval team, launched several hours before, arrived at this time and were able to transport the patient without difficulty on a ten hour flight, during which he was stable without the need for transfusion or further inotropes. Eighteen months later an Australian team preparing for deployment in Holland became aware of his further good function when casually reading an article in a Dutch Army magazine.

Commentary:

The coagulopathy of trauma9 exacerbated by hypothermia and acidosis (i.e. “lethal triad”) nearly killed this soldier, and this case illustrates the comprehensive system of care that is required for supportive medical treatment of such cases. Blood products in sufficient amount are required. Crystalloid to replace volume should be restricted as much as possible. Red Cells with platelets and fresh frozen plasma are recommended to be given in a 1:1:1 ratio from the outset9, 16. Although a walking blood bank can provide warmed coagulation factor and platelet rich blood, it was not available in this situation. A frozen blood bank was, and through this means the massive transfusion required was achieved16. Greater than 100 units of blood products were transfused including 65 units of packed cells and 25 units of platelets (note larger volume than Australian equivalent). Without a frozen blood back with its capacious supply it is possible that his transfusion requirements

Table 2: Laboratory results on return from OR.

Figure 7: UK Critical Care Evacuation Team

would not have been met by a walking blood bank. Even then it required hard work by technicians as the frozen blood must be washed and prepared. Two persons can produce 6 units of blood in two hours from a frozen supply. Defrosting of platelets and fresh frozen plasma is quicker.

Acidosis alone promotes coagulopathy by impairing thrombin generation, is critical to optimal coagulation function and thus needs to be aggressively managed. This was achieved by volume loading with blood components once haemostasis was obtained. The desired end-state required is the restoration of a normal blood lactate, base deficit or pH as the ultimate goal9. This was achieved in the ICU, after some time and collaborative hard work.

Despite knowledge of the adverse effects of hypothermia as an independent variable for mortality in trauma9,18,19the treating team were challenged to keep this patient warm. The exposure required for resuscitation and surgery and the volume of fluid transfused, despite active warming of the patient and blood product, mitigated against maintenance of core temperature. His temperature was a dangerously low at 33.4 C on arrival in ICU. Events simply moved to fast on this occasion. Wishaw has outlined the physiology of hypothermia and mechanisms for rewarming20.

The patient received Factor VIIa on three occasions, and it was not till the patient’s acidosis and hypothermia were corrected, that a larger dose in combination with Vitamin K reversed his coagulopathy. At the time of this case the early use of Factor VIIa was thought to be associated with a fall in early mortality in severely wounded combat casualties21, but later evidence

has shown this not to be the case though it is associated with a lower need for blood product22. Tranexamic acid is becoming increasingly used in major trauma and likely will have an increasing role with similar cases in the future23. It was not available in this case.

His story was one of a profoundly quick physiological deterioration after injury and a long fight in ICU to reverse this.

Oxygen supply can be problematic. One ventilated patient on FiO2 50% with tidal volume 700mls at 12 breaths/minute needs 7,000 litres in 24 hours. In other words 10 Australian E Cylinders. Probably a portable oxygen generator is the best way to produce the very large amounts needed in all areas of a forward hospital.

Even in the forward surgical team the addition of an Intensivist is considered by many to be essential. This case illustrates the complex care required in the ICU, and it may be too much to expect a single anaesthetist to manage such a patient and keep working in an operating room on other cases. Fortunately this episode occurred at a time of relief in place, and support could be given by the departing team.

Holcolmb9 makes the point that damage control resuscitation continues from arrival in the resuscitation bay through the OR and into ICU much more often in the severely injured battle casualty than in civilian practice. This supports the argument for an ICU physician separate to the Anaesthetist. This certainly was the case here, and for this reason is so illustrative of resources and personnel required for effective treatment.


Finally the care provided in this challenging case occurred on the platform of a physically robust hospital with excellent pharmaceutical and logistic support and adequate personnel. It represented the best that four nations could provide in cooperative health care and is the minimum standard expected.

Acknowledgement: the authors would like to thank their Dutch Colleagues who allowed us to share the care of this patient and learn from the events.

ReferencesChampion HR. Holcomb JB. Young LA. Injuries from explosions: 1. physics, biophysics, pathology, and required research focus J Trauma. 2009: 66(5):1468-77; discussion 1477.

Langworthy MJ. Smith JM. Gould M. Treatment of the mangled 2. lower extremity after a terrorist blast injury. Cln Orth & Rel Res (400- 422):88-96

Owens BD, Kragh JF, Wenke, JC, Macaitis JBS. Combat Wounds 3. in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2008 64 (2 ):- 295-299

Bellamy RF: Trauma System Development and Medical Evacuation in 4. the Combat Theater in Nessen SM, Lounsbury DE Hertz SP eds: War Surgery in Afghanistan and Iraq. A Series of Cases 2003-2007. Office of the Surgeon General, Borden Institute 2008 1-12.

Goldberg, M. (2010). Death and Injury Rates of U.S. Military 5. Personnel in Iraq. Military Medicine, 175(4), 220-6.

Cordts PR, Brosch, L A Holcomb J B 6. Now and Then: Combat Casualty Care Policies for Operation Iraqi Freedom and Operation Enduring Freedom Compared With Those of Vietnam. J Trauma 2008: 64 Supp pg. S14-S20

Butler, F., Holcomb, J., Giebner, S., McSwain, N., & Bagian, J. . Tactical 7. Combat Casualty Care 2007: Evolving Concepts and Battlefield Experience. Military Medicine: 172(11), 1-19.

Champion HR.A Lessons-Learned Legacy 8. J Trauma. 2008; 64:S2–S3.

Holcomb JB. Damage Control Resuscitation The 9. J Trauma 2007 62(6) Supplement; S36-S37

Darley DS, Kellman RM. Otological considerations of blast injury. 10. Disaster med. public health prep. 2010; 4(2): 145-52

Ritenour AE, Wickley ABS, Ritenour JS, Blackbourne LH et al 11. Tympanic Membrane Perforation and Hearing Loss From Blast Overpressure in Operation Enduring Freedom and Operation Iraqi Freedom. J Trauma 2008 64 (2 ):- S174-S178

Bass CR, Rafaels KA, Salzar RS. Pulmonary Injury Risk Assessment for 12. Short-Duration Blasts. J Trauma. 2008; 65:604–615.

Rotondo MF, Zonies DH. The Damage Control Sequence and 13. Underlying Logic. Surg Clin North Am. 1997; 77:761–777.

Schwab CW. Introduction: Damage Control at the Start Of 21st 14. century. Injury. 2004;35:639–641

Holcomb JB, Helling TS, Hirshberg A. Military, Civilian, And Rural 15. Application of the Damage Control Philosophy. Mil Med. 2001; 490-493

Neuhaus SJ , Wishaw K, Lelkens C. Australian Experience With 16. Frozen Blood Products On Military Operations Med J Aust 2010; 192 (4): 203-205

Arthurs Z, Cuadrado D, Beekley A, et al. The Impact of Hypothermia 17. on Trauma Care At The 31st Combat Support Hospital. Am J Surg. 2006; 191:610–614.

Gentilello LM, Jurkovich GJ, Stark MS, Hassantash SA, O’Keefe GE. Is 18. Hypothermia in the Victim of Major Trauma Protective or Harmful? A Randomized, Prospective Study. Ann Surg. 1997; 226:439–447; discussion 447–449.

Martin RS, Kilgo PD, Miller PR, et al. Injury-Associated Hypothermia: 19. An Analysis of the 2004 National Trauma Data Bank. Shock. 2005; 24:114 –118.

Wishaw KJ: Mild hypothermia in the battle casualty 20. ADF Health 2010; 1:21-23

Spinella, PC, Perkins J G, McLaughlin D F et al. The Effect of 21. Recombinant Activated Factor VII on Mortality in Combat-Related Casualties With Severe Trauma and Massive Transfusion J Trauma: 2008; 64(2) 286-294

Hauser CJ, K Boffard K, Dutton R, Bernard GR et al, Results of the 22. CONTROL Trial: Efficacy and Safety of Recombinant Activated Factor VII in the Management of Refractory Traumatic Hemorrhage J Trauma. 2010;69: 489–500)

CRASH-2 trial collaborators .Effects of Tranexamic Acid on Death, 23. Vascular Occlusive Events, and Blood Transfusion in Trauma Patients With Significant Haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet On Line June 15, 2010 DOI:10.1016/S0140-6736(10)60835-5

Australian Medical Taskforce team (AUS MTF 1) at Tarin Kowt, Afghanistan.


The medical sector astounds people on a near daily basis with exciting advances, but for some reason, the old paper medical records system continues to plague healthcare.

But right now Joint Health Command is playing a key role in making sure records management can finally align with the advances in practice, as the ADF takes a key national leadership role in the introduction of electronic health records throughout Australia.

As one of only two organisations providing healthcare on a national basis – the other being the Department of Veterans’ Affairs (DVA) – the ADF’s eHealth initiatives have the potential to influence all Australian state and territory health jurisdictions and most of the private providers of healthcare, despite being a relatively small (in dollar terms) e-health project.

A national eHealth system is a key Commonwealth and state government priority, and medical industry interest groups are investing significant policy and technical expertise into a national system. That means Defence’s groundbreaking work with its fledgling system could have significant breadth and depth of penetration of the local healthcare industry.

In December 2008, the Australian Government issued its National eHealth Strategy. The aim of the strategy is to allow every Australian to have an electronic health record that can

e-Health

Australian Defence eHealth - JeHDIbe accessed by authorised health care providers anywhere in the country, benefitting those who regularly move around the country, such as Defence families.

Defence is therefore a major stakeholder in ensuring the Commonwealth meets its national objectives. This is reflected in the strategic objectives of Australia’s Defence Healthcare organisation, Joint Health Command.

Among JHC’s objectives to deliver effective and efficient healthcare, and support Defence operations is to provide “Required health knowledge … through [an] eHealth system.”

Specifically, the architects of the Defence system have said the implementation of an eHealth system will deliver:

Electronic health records •

Capable of operational use •

Health Management•

Research tool•

Other National agency involvement •

Individual ownership of health•

The JeHDI Project will deliver the implementation of an ADF electronic health information system linking health data from recruitment to discharge by December 2013, and ensure that from the time a person is born in Australia, move through to adulthood and a military career, and back into the civilian arena, they will have a comprehensive and seamless management of their healthcare records. n

All members of the Defence Health Service are eligible to receive a copy of ADF Health.

Full-time members receive their copy via a bulk distribution to health units/facilities.

Full-time members not posted to a health unit, and all other members, can request a personal copy.

To add your name to the mailing list, remove your name, or change your address details, contact:

Captain Brendan Byrne, Defence Health ServiceEmail: [email protected]: (02) 6266 2143Post: CP2-6-065, Campbell Park Offices, CANBERRA ACT 2600

Captain Byrne should also be contacted if a unit is not receiving copies or if the quantity needs to be changed.


The Centre for Military and Veterans’ Health (CMVH) has its finger on the pulse when it comes to understanding

the professional development needs and aspirations of Australia’s military health personnel.

With Defence health at the heart of its existence, the CMVH has developed a range of short and long-term courses designed to address the need for tertiary education for Defence Health Services and the Department of Veterans’ Affairs, including Australian Defence Force personnel, contractors, public servants and civilians.

The Masters of Public Health (Defence) and has been designed to align with Australian Defence Force requirements and proposed career structures. Students are equipped with the academic, professional and management attributes that will enable them to approach Defence health issues from a population health perspective.

The Masters of Psychology (OMH) has been designed to address the broad and eclectic Defence environment and is able to provide Defence psychologists with the necessary skills required for providing health care and organisational support to ADF personnel.

The CMVH’s range of specialised short courses include Health Aspects of Disaster, Communicable Disease Control, Introduction to Military Medicine and Occupational and Environmental Health. These courses are particularly beneficial to those who want to hone their medical, nursing and allied health skills in a world where Defence personnel are heavily involved in disaster management and global environmental health

CMVH’s collaboration with the University of Queensland, University of Adelaide and Charles Darwin University provides students with a national resource and a wide range of specialist study areas, study options and locations. The CMVH is constantly investigating professional development opportunities and there are a few exciting options on the horizon!

CMVH courses are internationally-renowned and accredited. Students can gain credit for

other courses undertaken with the Australian Defence Force. Students may be eligible to transfer credit for study completed at another university, TAFE or Defence learning institution as part of the Public Health (Defence) Program.

EducationA D V E R T O R I A L

Centre for Military and Veteran’s Health offering internationally-renowned courses

To find out more about CMVH Defence health courses contact the Professional Development Officer on (07) 3346 4940, [email protected].

au or visit www.cmvh.org.au


MilHOP will inform the development of a robust, evidence-base approach to the specific health needs of ADF personnel resulting from the deployment experience. Information provided from MilHOP will support the development of targeted health programs designed to meet the health needs of deploying ADF personnel now and into the future. The data will also inform the development of Department of Veterans Affairs (DVA) Statements of Principle (SOP), which rely on published scientific data to identify any causal links between deployment exposures and subsequent ill health.

The MilHOP study consists of four surveys, across two studies:

The Middle East Area of Operations (MEAO) Health •Study, which comprises:

A Prospective Survey1.

A Census Survey2.

The MEAO Mortality and Cancer Incidence Survey3.

The Health and Wellbeing Survey•

The MEAO Health Study and surveysThe MEAO Health Study is designed to ascertain the health status of ADF personnel who have deployed to the MEAO. It will investigate specific chemical, physical, biological and psychological exposures and other risk factors where changes in health outcomes are found.

MEAO Health Study 1 - The Prospective StudyThis survey involves recruiting currently serving ADF personnel approximately four months prior to deployment to the MEAO, and following them up four months after their return from deployment. It is estimated that 3,000 personnel will be eligible to participate in this study, and it will focus on those deploying to Afghanistan between July 2010 and late 2011.

At each time point, all participants will be asked to complete a self-administered questionnaire on their health, exposure to potential hazardous substances, and in general an insight into their deployment experiences.

A subset of deploying personnel (approximately 750 participants sourced mainly from specialist units such as the Special Forces and Combat Engineering Regiment) will also be asked to take part in a series of physical tests. Additionally, sub sample of

MilHOP Study

The Military Health Outcome Program (MilHOP)

In order to identify, plan and implement a progressive Defence healthcare system and services that meet the need of a modern Defence Force the ADF is undertaking its largest and most comprehensive study of current and former personnel.

The Military Health Outcomes Program – or MilHOP as it has come to be known – is an AU$12 million research program that commenced in April and will conclude with a final report presented to Defence leadership in June 2012.

Drawing on the expertise of the Centre for Military and Veterans’ Health (CMVH – see related article) and helping the ADF meet the recommendations of the Dunt Review into Defence Mental Health (see related article), MilHOP has at its core the intention of better understanding the health and wellbeing of ADF members, which reflects the belief of Defence Senior Leaders that people are the ADF’s greatest asset.

That core value is more than just a glib throwaway to appease public cries for a more humane management of men and women in uniform. It is actually being demonstrated and given substance by the considerable investment into new and improved Defence health initiatives in areas such as mental health, rehabilitation and eHealth projects (see related articles on all these topics).

At the forefront of these initiatives are an additional AU$83 million dollars in mental health and AU$155 million to enhance ADF Rehabilitation services. These figures assume greater weight when considering the relative sixe of the ADF – 56,000 permanent members and 21,000 reservists.

HISTORICAL STUDIESSince 2000 the Federal Government has conducted formal health studies on major overseas deployments to the Australian Near North Area of Influence.

The Deployment Health Studies Program was established to provide a systematic and ongoing means of assessing and understanding the health effects of deployment on ADF personnel. Studies have recently been completed on deployments to the Solomon Islands (2008), East Timor and Bougainville (2009).

While the research from these studies has informed the MilHOP Study, relatively low participation rates limited the conclusions that could be drawn. Without a high participation rate, the impact of deployment on the health status of personnel cannot be clearly defined.


these participants (approximately 100 Special Forces personnel will also participate in neuro-cognitive testing). This study commenced on 23 April 2010.

MEAO Health Study 2 - The Census StudyThe Census Study collects retrospective data from all 27,000 ADF personnel who have deployed to the Middle East between 1 October 2001 and 31 December 2009. The study collects data from serving personnel through a self-administered questionnaire addressing Brief Deployment History, health and deployment experiences, and commenced in May 2010. Data will be sought from ex-serving members until late 2011.

It is being conducted by the CMVH University of Queensland node and aims to ascertain the physical, emotional and environmental effects of deployment in order to better manage the health care needs of current service personnel and veterans.

MEAO Health Study 3 - The MEAO Mortality and Cancer Incidence StudyCMVH will collect data on deaths and cancers from the Australian Institute of Health and Welfare. Serving and ex-serving members will not be required to actively participate in this study. Communication with Defence and the ex-serving community will not be required for this component.

The Health and Wellbeing SurveyThe goal of this study is to establish the prevalence of mental health conditions in the ADF. This study is being jointly conducted by the Directorate of Mental Health, and the University of Adelaide (UA) node of CMVH. The study will use a self-report questionnaire and a clinician-administered interview for selected cases.

The Health and Wellbeing Study will collect information from personnel who are in the ADF but who have not deployed to the Middle East. Over 30,000 currently serving personnel will be invited to participate. This information will be combined with information from the MEAO Census Studies to determine the prevalence of mental health conditions in the ADF. This study is a key initiative of the Mental Health Reform Process resulting from the Dunt review. The study was released on the internet on 23 April 2010.

Using data from these studies, the ADF and Federal Government will have an opportunity to plan for a holistic approach to Defence and veterans’ health needs for the first time. In his Review of ADF Mental Health, Professor David Dunt recognised the need for accurate baseline mental health data to provide effective services for all Defence Force members. Such baseline information will allow the ADF to identify what services are required and what programs are most needed.

LTGEN David Hurley, Vice Chief Defence Force with the MilHOP staff

The Health and Wellbeing Study will identify risk factors for currently-serving ADF members, as well as identify cultural and organisational factors which may increase stigma and barriers to mental health care. The ADF’s current post-deployment screening programs will also be evaluated for their usefulness.

The Health and Wellbeing Study’s first component is an online survey of all personnel not previously deployed to the Middle East. Data from the MEAO Census and this online Survey will be combined to provide baseline estimates of mental health issues and psychological distress in the ADF.

In the second component, a subset of 1,400 personnel will be invited to participate in a one-hour clinical telephone interview. These interviews will provide validation of psychological screening measures currently administered to all ADF members following operational deployment. These telephone interviews will also test the accuracy of self-report information collected during the online Health and Wellbeing Survey.

Like any survey, the number of participants increases the validity of the collected data. The ADF has embarked upon a promotional campaign to raise awareness of MilHOP and encourage commanders to make the survey available to every serving member.

The core messages of the campaign are that MilHOP is about gathering health data in order to develop more effective and ongoing support services, and that if contacted by CMVH,

members and veterans should consider participating for the benefit of themselves, their family, other veterans and especially their mates.

Engagement with the broader Defence community is essential to achieve the desired participation rates. Ex-Service Organisations are especially important in encouraging ex-serving veterans to participate. .Families and friends of serving and former Defence members are also acknowledged as often being the greatest ‘influencers’ on personnel and veterans. It is hoped that family and friends can help someone wavering about undertaking the survey to go ahead and complete it.

Without a detailed understanding of the effects of operational deployments, Defence cannot develop policies and provide the services that members may require. Broad ADF participation in MILHOP provides an opportunity to shape the future. n

More information on the MilHOP studies can be found at the Defence website – www.defence.gov.au – or at the CMVH site – www.cmvh.org.au


The ProgramThe ADF is partnering with the Australian Paralympic Committee (APC) to give Australian military personnel the support they need to meet their goals. Through this partnership, the ADF will be able to put into place a series of services which will assist these members to reintegrate and overcome their challenges.

The APC and the ADF are working together to develop week-long high performance camps, where members are brought together twice a year to undertake a variety of activities. ADFPSP members will access:

injury specific rehabilitation and physical fitness programs •to again reach peak fitness;

introductions to Paralympic Sports and talent testing;•

instruction on how to run, swim, handle weapons, and other •fundamental military tasks again, without further injury;

education on injury specific or more sports medicine •orientated topics such as nutrition, recovery techniques, sports psychology or prosthetics;

adventure training and activities that will stretch, challenge •and develop members.

The ADF will be supporting local physiotherapists and physical training instructors in the delivery of programs by letting them draw on the ADF’s expertise and experience. This is all supported by the APC’s sports science and sports medicine department.

Program members ADFPSP members are drawn from a variety of different backgrounds. Motor bike or motor vehicle accidents, injuries and wounds sustained while serving on deployment, and through illness. What members share and are united by is their choice to wholeheartedly pursue their remarkable ‘abilities’ rather than bow down to the challenges of acquired disability.

Membership to the ADFPSP is restricted to currently serving ADF members who meet the national classification criteria for an Australian Paralympic Sport. The coaches and training partners of athletes are also welcome and eligible for membership.

In addition and based on the advice from ADF members, a whole series of information resources will be developed to support them and their families on understanding their injury,

Sport & Rehabilitation

ADF Paralympic Sports: Striving to win against all oddsEquality, courage, compassion, teamwork and initiative in overcoming adversity

Chief of Army LTGEN Ken Gillespie sitting down with one of the ADF paralympians who is wearing his prosthetic leg during a training session.

To help support severely wounded and injured military personnel continue their career, the Australian Defence Force (ADF) has established the ADF Paralympic Sports Program (ADFPSP). The ADFPSP and Association (ADFPSA) contributes to the rehabilitation and gaining of functional independence of ADF members by facilitating and supporting the attainment of physical fitness and an active lifestyle through the participation of adaptive sport.

the adaptations required, and how to access a wide range of ADF services. This will also include changes to some ADF policies such as equitable access to sport.

MATES mentoring program With a “been there, done that” attitude, one of the elements of the ADFPSP is the MATES mentoring program that is currently under development.

The MATES program will provide well-adjusted members who are living a full life with additional training on how to be a positive force as a peer visitor and mentor. They will receive training on effective communication, listening and sensitivity training; understanding the process of grief and loss; techniques for interacting with injured colleagues and health professionals; and obtain information resources on acquired disabilities and support services.

In the near future, it will be an ADF member with a similar injury who will be a MATES mentor and help a colleague through the rehabilitation process.

BackgroundOn 8 February 2010, the Chief of the Defence Force agreed to be Patron of the ADF Paralympic Sports Association. The ADFPSP / ADFPSA initiative is a result of a Memorandum of Understanding (MOU) that was signed between ADF’s Joint Health Command and the APC on 11 February 2010.

The signing of a MOU with the APC will see the delivery a number of services to further improve the physical rehabilitation of ADF members who have acquired a disability during their period of service. Through this partnership, identified ADF members will be aligned with Paralympic sporting pathways, which will provide them with equitable access to sporting opportunities through to the elite international level.

Use of Sport in RehabilitationThe modern day Paralympic Games dates back to 1948 when the Stoke Mandeville Games were held for severely injured World War II Veterans. Since then, modified sport has played a very important role in the rehabilitation of servicemen with significant impairments or acquired disabilities, enabling them to successfully return to an active life. The use of sport and outdoor activities has a proven track record in aiding physical and psychological rehabilitation through:

the optimisation of functional independence and physical •fitness;

development of a positive self-image and self esteem;•

health promotion;•

sportsmanship;•

leadership and camaraderie;•

quality of life; and•

greater awareness among ADF personnel of the effects of •and support for members with an acquired disability. n


Conference Program

Thursday, 28th October 20101100 Registration Desk Opens

1300 Optional guided tour of the Australian War Memorial

1800 – 2000 Welcome Reception National Convention Centre

Friday, 29th October 20100730 Registration Desk Opens

0830 Symposium Welcome and Welcome to Country Dr Greg Mahoney, President, Australian Military Medicine Association

0845 – 0900 Symposium Welcome MAJGEN Paul Alexander Commander Joint Health

0900 – 0920 Official Symposium Opening

0920 – 1030 Keynote Presentation BRIG GEN Van der Meer CDRE Hans Jung RADM Mittelman Regional cooperation in disaster relief

1030 – 1100 Morning Refreshments

1100 – 1230 Session 1 Mental Health Symposium 1

Session 2 History

Session 3 Training, Recruitment

and Retention

Session 4 Early Management of

Trauma and Pre-hospital care

Session 5 Defence Research

Stephanie Our Lost Colleagues of HMAS SYDNEY II – The Medical Officers and Sick Berth Attendants of “The Stormy Petrel”

Scott Finlayson

Training the Military Surgeon for the Australian Defence Force

Jeffrey Rosenfeld

Special Forces: Battlefield Trauma Care Training

Introduction of the MRH90 Helicopter and TopOwl Helmet for Operational Use by the Royal Australian Navy

Glenn Pascoe

Tropical Medicine and the Great War. The Contribution of the Australian Army Medical Corps

Geoffrey Quail

Non-Technical Core Competencies for Surgeons in Disaster Response – The Need for a Training Program

Bruce Waxman

Hypothermia and the Battle Casualty

Recognising Early Deteriorating Signs a Project at Kapooka Health Centre

Vicki Pocius

Endurance, Courage and Care: The 1942 Kokoda Track Campaign of Captain Alan Watson, Dental Surgeon

Barry Reed

Roles of Consultant Physicians in the Australian Defence Force (ADF)

Bill Heddle

Surgical Workload at the Role 3 Multinational Medical Unit, Kandahar Airfield, Afghanistan

Katrina Franke

The Cost and Outcomes of Spinal Surgery in a Military Cohort

Stephan Rudzki

A Hero - Sometimes Forgotten

Michael Dowsett

The Growth of Paramedic Roles and the Urgent Need for National Standards

James Ross

Combat-related Maxillofacial Injuries: the Kandahar Experience

Daryl Tong

Towards a Better Understanding of the Physical and Mental Health of ADF Personnel

Carol Davy

1230 – 1330 Lunch

1230 – 1330 Meeting of Chairs of Regional Triumvirates


Friday, 29th October 2010 (continued)1330 – 1530 Session 6

Mental Health Symposium 2

Session 7 Occupational Health and

Safety

Session 8 Rehabilitation



Session 10 Preventative Health

and Promotion

Stephanie Real-world Attenuation of Foam Earplugs

Adrian Smith

Occupational Rehabilitation in the ADF

Jane Hayter

Disaster and Mass Casualty response

Jeff Stephenson

The US Army Public Health Command Initiative: Transforming Public Health Services for the US Army

John Resta

Lessons Learnt from a Heatstroke Death

Stephan Rudzki

Reflections On A New Initiative: Case Co-ordination for Clients with Complex Needs

John Fely

Prehospital Care of Severe Head Trauma Abstract

Ben Manion

Comprehensive Soldier Fitness In Forces Command

Georgeina Whelan

Navy Asbestos Containing Material (ACM)

Life After Amputation – Ignorance Is Not Bliss

Microcirculatory Changes in Response to Smoke Inhalational Injury

Anthony Holley

Dental Blitz: The Three Week Campaign of the AACAP Dental Team at Doomadgee

Barry Reed

Welding Injuries to the Ear: From the Superficial to Deep

Australian Defence Force Paralympic Sports Program & Association

Case Report of Thoracic Spine Fractures from IED Blast in an Armoured Vehicle

Changes over Time in the Healthy Soldier Effect

Michael Waller

1530 – 1600 Afternoon Refreshments

1600 – 1645 Keynote Presentation NATO and Coalition Medical Presentation Col Wynand Korterink LTCOL Andrew Dunn NZ Defence Force

Saturday, 30th October 20100730 Registration Desk opens

0815 – 0830 Welcome to the Day and Housekeeping

0830 – 0930 Keynote Presentation David Mearns

0930 – 1030 Keynote Presentation Dr Charles Rice


1100 – 1230 Session 11 Mental Health

Session 12 Operational Health /

Miscellaneous



Session 14 Governance

Session 15 Health Surveillance

The Post Deployment Adjustment of Army Reservists from Stability Operations: A Winning Combination?

Geoffrey Orme

Australian Medical Task Force 5 (AUSMTF5)

Robyn Tatnell

The Face of War: The Modern Management of Battlefield Ballistic Facial Injuries

Andrew Gibbons

Innovation in Joint Health Command Clinical Governance

Helen Murphy

Longitudinal Health Surveillance of Military Populations – Is It Worthwhile?

Are Suicide Rates for Young Australian Males Really Falling? The Recent Controversy Explained

Duncan Wallace

The Next Phase in Operational Health Models – Embedding Health Professionals

James Ross

Development of a Short Training Course for ADF Health Care Personnel in the Primary Care of Maxillofacial - Barry Reed Wounds from Battlefield Trauma

Clinical Governance and Deployed Health

Amanda Jane Currie

Deployment and Post-Deployment Experience of Women in the East Timor and Bougainville Deployment Health Studies

The Protective Effect of Hardiness on Australian Army Reservists Deployed on Stability Operations

Geoffrey Orme

The Loss of HMAS SYDNEY II: Medical Aspects

Managing Expectations - Can We Really Call on Our Big Blue Brother?

Susie Busch

An Introduction to Human Research Ethics for First Time Defence Researchers

Isaac Seidl

Posttraumatic Stress Disorder and Hypertension Amongst Australian Veterans of the 1991 Gulf War

Dental Treatment for Veterans Suffering from PTSD

Mobile Field RAP, Regimental Aid Post

JP2060 Phase 3 - The Future Joint Health Operational Concept

Mental Health of Women in the Near North Area of Influence Deployment Health Studies

1230 – 1330 Lunch


Saturday, 30th October 2010 (continued)1230 – 1330 1HSB/Counter -IED Taskforce Clinical Performance Improvement Team (TBC)

1230 – 1330 AGM of the Joint Health Command Anesthesia Consultative Group (TBC)

1230 – 1330 JHC Clinical Advisory Board (TBC)

1230 – 1330 Meeting of Chairs of Regional Health Triumvirates (TBC)

1330 – 1440 Session 16 Mental Health

Session 17 Operational Health /

Miscellaneous



Session 19 Governance

Session 20 Health Surveillance

1 Psych Unit Support to Operations - Unit Presentation

Force Preservation and Enhanced Rehabilitation Services: Lessons from a High Tempo Environment

How did we get there and where are we going

Presentation and demonstration by Col Graham Durant – Law

Pilot Selection Anthropometry - a Comparison with Measures Taken by a Single AVMO.

Urological Injuries

CAPT Art Smith USN

The HMAS Kuttabul Clinical Pilates Rehabilitation Programme

Anna Lewis

Civilian Aeromedical Evacuation in Support of the ADF

James Ross

Understanding the Impact of Military Deployment on Families: An Australian Study

Contagious Diseases, International Health Regulations and Aeromedical Evacuation

Jeff Stephenson

Australian MIMMS initiative - National Critical Care and Trauma Response Centre (Len Notaras and Ian Norton)

1440 – 1510 Afternoon Refreshments

1515 – 1645 Session 21 Hypothetical: Disaster Control

1700 – 1800 AMMA General Meeting

1900 Symposium Dinner

Sunday, 31st October 20100800 Registration Desk Opens

0850 – 0900 Welcome to the Day and Housekeeping

0900 – 1000 Keynote Presentation Minister for Defence and CDF


Keynote Presentation Dr Charles Rice Traumatic Brain Injury in Military Service Members

Keynote Presentation

1240 – 1300 Closing Presentations and Awards

1300 Farewell Lunch

Documents

ADF Health 2010