ADF Health 2009

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ADF Health

Journal of the Australian Defence Health Service

STRENGTHENING HEALTH IN DEFENCE

Contents 3

Editorial: ‘A more cost-effective Journal’ CAPT Mike O’Connor RANR

4 Guest Editorial: ADF Military Ethics: Quo Vadis?

Mr Jamie Cullens

9 The Defence White Paper and its Implications for Defence Health

MAJGEN Jeffery Rosenfeld ,CAPT Mike O’Connor

14 Simulation training for ADF surgical and intensive care teams:

a pilot study LCDR John Vassiliadis, LTCOL Richard Mallett, FLTLT Stephanie

O’Regan, Dr Ken Harrison, Dr Adam Rehak, COL Susan Neuhaus.

20 The Mental Health Reform Health Process (Dunt Report):

A Support System for ADF Personnel LTCOL Stephanie Hodson,Ms Lyndall Moore,MAJ John McGrogan

23 Return to Sender: Reintegration after Reservists Deploy

LTCOL Geoffrey Orme

29 Definitive Surgical Trauma Course

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29 Honours and Awards 31 Field Anaesthesia Training for the Australian Defence Force

GCAPT George Merridew

34 Medical Officer Underwater Medicine Course

LEUT Peter Smith RAN

37 The ADF Aviation Medical Officers (AVMO) Course

SQNLDR Adam Storey

39 NSW Military Health Symposium

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40 Deployed Surgeons Obstetrics and Gynaecology Skills Course

CAPT Mike O’Connor RANR

44 Medicine in the time of Elizabeth

Dr Con Reed

48 Imhotep and the Origins of Ancient Egyptian Military Medicine

AVM (Ret’d) Bruce Short.

52 Geneva: an ‘illusion of knowledge’ for ADF medical officers?

Front Cover: Resuscitation in the PCRF

ADF Health | Vol 10 No. 1 | 2009

CAPT Mike O’Connor RANR

58 Obituary: Sir William Refshauge

CDRE (Ret’d) Mike Flynn

60 Letter to Editor: CAPT Nick Gray 1



ADF Health Journal of the Australian Defence Health Service ISSN 1443-1033

Editor Captain M C O’Connor, AM, MB BS (Hons), MD, MHL, DCH, DDU, FRCOG, FRANZCOG, FACLM, JP, RANR Chairman, Editorial Board Major General J V Rosenfeld, MB BS, MD, MS, FRACS, FRCS (Edin), FACS, FRCS (Glasg) Hon, FACTM, MRACMA Assistant Editors Lieutenant Colonel K L Clifford, RN, GradCertEmerg, GradDipMid, MHA, MPH, MRCNA, MCN, AFCHSE, RAANC Colonel S J Neuhaus, CSC, MB BS, PhD, FRACS, RAAMC Lieutenant Commander SPS Rayner, RANR, BA (SS), MA, MClinPsych, DPsyc (Clinical) Professor GD Shanks, BS, MD, MPH, FACTM, Director, Army Malaria Institute Major M B Tyquin, PhD, BEc, BA (Hons), MStJA, MPHA Group Captain P S Wilkins, MBE, BA, MB BS, MHP, MLitt, FRACMA, FAFOM, FAFPHM Production Manager Claire Henry Editorial Consultants Major General J H Pearn, AO, RFD, MD, BSc, PhD, D.Sc (hons causa), FRACP, FRCP, FACTM, FAIM Air Vice-Marshal B H Short, AM, RFD, MB BS, FRACP, FCCP, FACP, FACTM Publication Administrator CAPTAIN 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: brendan.byrne@defence.gov.au 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.

Adbourne PUBLISHING

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ADF Health | Vol 10 No. 1 | 2009

A more cost-effective Journal

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n this edition you will have noticed a radical change in format. The Strategic Reform Program (See Rosenfeld et al in this edition) has not spared ADF Health. Our budget was cut by 80 percent. Reliance for funding must now come largely from advertising revenue. At this stage the Editorial Board has determined that there will be only one edition per annum. I am particularly grateful to MAJ Mike Tyquin, LCDR Steve Rayner and AVM Bruce Short (Ret’d) who have shouldered much of the extra editorial responsibilities. In this edition we are profiling some of the specialist courses available to ADF health officers: Aviation Medicine (AVMED), Underwater Medicine, Deployed Surgeons O&G Skills course (DSOGS), Military Anaesthesia (MILAN) and Predeployment Surgical Simulation Training.LTCOL Orme has written a paper on post deployment re-entry and reintegration challenges for reservists. In addition there are two papers on military medical history which cover Elizabethan and early Egyptian medical science. There is a paper on ADF medical officers’ understanding of the Geneva Conventions and a guest editorial by Mr Jamie Cullens, Director of the Centre for Defence Leadership and Ethics (CDLE) Joint Education, Training and Warfare Command. This addresses the initiatives to improve ethics training in the ADF. That was a principal recommendation of the CMVH Think Tank meeting ‘Towards a Framework for Military Health Ethics’ in October 2006 .There has been great enthusiasm expressed by many senior officers about the new Defence White Paper. MAJGEN Rosenfeld has highlighted the key points of the Paper including its implications for Defence Health. Another important recent review (Dunt) of ADF mental health services is summarised by LTCOL Hodson et al. The operational tempo of Joint Health Command continues to remain at a high level with demands for health support in many areas of operation. In Afghanistan our surgical teams continue to excel under busy and difficult conditions. Our respect and gratitude go out to them.

Captain Michael O’Connor Editor, ADF Health

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Guest Editorial

ADF Military Ethics: Quo Vadis? Jamie Cullens BA.MA, Grad Dip Management Director, Centre for Military Leadership and Ethics, Joint Education, Training and Warfare Command, ADF.

Jamie served in Infantry after graduating from the Royal Military College, Duntroon in 1976. His career consisted of command (platoon, company and regiment), staff and training postings and included a two year posting with the US Army’s Rapid Deployment Force in 1989-90. He saw operational service in Kashmir with the United Nations and on Operation ‘Just Cause’ in Panama with US forces; attended Army Command and Staff College in 1988; and, commanded NORFORCE in the Northern Territory and Kimberley regions of Australia in 1994 - 95. Jamie was appointed as the first Director of the Centre in 2002. Operating as an implementing ‘think tank’, the Centre supports the development of command, leadership, management and military ethics programs in the Australian Defence College courses and across Defence. In 2005 the Centre worked with the Singapore Armed Forces in developing their operational leadership programs. The Centre also developed and continues to deliver the One/Two Star Operations (OBOE) course for the Chief of the Defence Force and the command and leadership component of the Navy Command Course.

Military Ethics – is there a problem? Ethical issues on operations continue to make headlines in the world’s media. For example, on one day in September 2009, The Australian ran three stories on separate military ethical issues. The first related to the ransacking of an Afghan hospital by foreign troops in ‘a clear violation of globally recognised humanitarian principles about the sanctity of health facilities and staff in areas of conflict1’. The second related to the killing of civilians in an airstrike in Afghanistan. A United States Air Force aircraft launched that strike but it was called in by a German commander.2 The third was an Australian Defence Force issue where female Navy personnel had rescued Afghan refugees ‘after another boat carrying mostly male Navy crew abused and physically prevented Afghans – many with serious burn injuries – from boarding their rescue vessel3’. The truth behind the stories will be revealed in time, but the reports do underline the complex and difficult ethical environment of contemporary operations.

The operational experience of the Canadian Forces in Somalia in 1993 highlighted serious ethical failures. According to a Canadian officer, ethical failures ‘have involved military and public service personnel of all age groups, all elements and without regard to religion, ethnicity, gender or any other criteria4’. The Canadian armed forces continue to address these challenges through sophisticated educational programmes. Australia’s principal ally, the United States, has had enormous challenges with Fallujah, Abu Ghraib and Guantanamo Bay and all four services deliver comprehensive military ethics programmes from recruit through to star rank. In 2008, the United Kingdom’s Ministry of Defence released the Aitken Report5 which examined the abuse and killing of Iraqi civilians by the British Army in 2003 and 2004.

Ethical issues in the ADF Serious operational incidents in Australia in recent times have highlighted ethical problems. One example of this was the 1996 Black Hawk disaster discussed by Alan Tidwell in19996. Over the past decade the nature of ADF operational experience has raised ethical dilemmas for its commanders and personnel and the challenges in the South Pacific contingencies in the late 1980’s; Somalia in 1993; Rwanda in 1994-95; East Timor since 1999; and, the Solomons, Afghanistan and Iraq from 2003 onwards. There was also extensive commentary in the media about the ADF’s ethical challenges in the ‘Children Overboard Affair’ during the Australian election in 2001 which continued into 2009. These past and present operations demonstrate aspects of volatility, uncertainty, complexity and ambiguity. The fact that the ADF has performed to a high ethical standard in the past can be attributed to the quality of culture, selection, leadership, training and a degree of luck. However, the Senate report on the effectiveness of Australia’s military justice system (June 2005), highlighted areas of concern. These also need to be addressed in the professional educational environment. The subsequent Learning Culture inquiry highlighted further issues in training establishments. The current high tempo of the Australian Defence Force’s (ADF’s) overseas operations is likely to continue. This may be either in stand alone deployments or as part of a coalition where Australians are often in command. Leaders in the ADF need to be prepared for these challenges by education which includes the ethical issues that have emerged in recent conflicts,

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deployments and garrison incidents. This education needs to be supplemented by opportunities for debate and reflection. The ADF needs to understand that it can no longer afford to be reactive in this regard.

ADF initiatives in Military Ethics Until 2003 holistic military ethics education in the ADF was restricted to the introductory leadership and ethics education provided at the Australian Defence Force Academy and the Service colleges. As part of character development programs, Service chaplains taught modules in ethics to recruits. In specialty training units ethics was raised at best in an ad hoc manner. In 2008, as the recipient of the Secretary of Defence Scholarship, I was able to investigate the Australian Defence Force requirements for military ethics education in order to meet the challenges of contemporary operations and future conflict. With Australia’s open-ended commitment to Afghanistan and the possibility of future conflicts, often in a complex operating environment, it became clear that we need to enhance the ethical education of ADF personnel. The 2009 Defence White Paper7 noted that investment ‘in recruitment, training, education and the career development of the ADF’s junior personnel and leaders will continue to display substantial dividends in terms of our ability to achieve campaign objectives and reduced casualties, while maintaining the high ethical standards of ADF personnel (emphasis added), and the proud record of the ADF on operations.’ From 2003 onwards pilot military ethics programs were designed and offered to the Australian Command and Staff College and Centre for Defence and Strategic Studies .These programs have evolved following comprehensive student feedback. More recently ethical modules have been developed for the Army Grade 2 Command and Staff course as well as for the Navy sea and shore commanding officer/executive officer courses. Despite these positive developments little is done for ADF non commissioned officers. These junior leaders, who are often corporals in Army, are faced with the most challenging ethical dilemmas on operations and they need to decide very quickly as to what is the right thing to do. Their decisions have strategic consequences. What has become clear is that officers attending ADF professional military education courses want to spend more time discussing ethical issues. The non- commissioned officers have yet to be given the opportunity. The Defence College programs, conducted as workshops, use some of the principles suggested by the Harvard Business School: • Ethical teaching should emphasize attitudinal development as much as acquiring a set of skills and knowledge. • The ethical standards of outstanding leaders, organisations, and practice are valuable models. • The focus of ethical education should be on decision making with all its complexities and ambiguities. • Ethical issues should be raised early in the course to allow prolonged reflection during the year.

The programs use the tri-service values of professionalism, loyalty, innovation, courage; integrity and teamwork as the basis for discussion .They have an operational focus and contribute to the development of tactical, operational and strategic leaders by: • Recognition of the centrality of personal ethical values in the context of organisational effectiveness and national support of the ADF. • Developing an understanding of the breadth of responsibility of the modern military. The constraints and compromises which may be required when discharging that responsibility are also canvassed. • Encouraging course members to analyse the merits and demerits of their personal approach to military ethics. The content of these courses includes lessons which can be learnt from previous incidents in military operations: the 1968 My Lai massacre; the 1994 -95 ADF Rwanda experience; the 1996 Australian Black Hawk disaster; the NATO bombing against the Federal Republic of Yugoslavia in 1999; the HMAS Westralia fire in 1998; the Royal Australian Air Force F-111 deseal / reseal program; the highly politicised 2001 ‘children overboard’ affair in the Indian Ocean; the Abu Ghraib scandal in Iraq; the Dutch failure at Srebrenica in 1995; the Tarnak Farm fratricide in Afghanistan in 2002; and the Canadian Airborne Regiment experience in Somalia in 1993. The program also studies the Senate report on the effectiveness of Australia’s military justice system. In 2008 the case study on the Navy’s 2005 Nias Island Sea King crash was added to the curriculum. Although there are myriad good examples of appropriate ethical decisions, student feedback suggests that it is the organisational failures which attract the most debate and professional reflection. At the Staff College a separate command and ethics session is delivered by health personnel and this is well regarded. The leadership and ethics programs offer little in the way of solutions but a great deal of material for reflection: The truth about ethics and the human condition is that there is no prescriptive answer. It is judgemental and there are no assurances of certainty Dr Simon Longstaff, 2002. The workshops rely critically on the extensive collective operational experience of the participants and often include personal testimony from members who have been involved in incidents. In these workshops, the objectives include: • Considering ethical dilemmas and challenges for military. • Reflecting on what alternative solutions students might have developed when faced with similar dilemmas. • Recognising the power of personal testimony by individuals involved in challenging incidents. • Encouraging debate on the major ethical issues. The Joint Education, Training and Warfare Command approach to education focuses on achieving a balance between ‘how to think’ and ‘what to think’. Education in military ethics remains a key component of that process.

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In May 2009 the Chiefs of Service Committee endorsed a series of key recommendations for the study of military ethics. They included

References: 1.

a) the development of ethics education programs from recruit to two star level in the ADF

The Australian. 7 September, 2009. http://www.theaustralian.news.com.au/story/0,25197,2603686012377,00.html accessed 7 Sep 09

2.

b) the recognition that commanders must have ownership of ethics (it is not just the responsibility of chaplains, legal officers and medical staff)

The Australian. Gordon Brown calls for summit on Afghanistan. September 7, 2009. http://www.theaustralian.news.com.au/ story/0,25197,26036934-2703,00.html accessed 7 Sep 09.

3.

Dodd M. ‘Officers used feet to repel refugees’ The Australian. September 7, 2009. http://www.theaustralian.news.com.au/ thenation/ accessed 7 Sep 09.

c) the development of a Commanders’ Guide to Ethics, and

4.

d) the establishment of a Military Ethics Advisory Board (to include health representatives) chaired by a two star officer and reporting to the Vice Chief of the Defence Force.

Neill, D.Ethics and the Military Corporation.Canadian Military Journal, Spring 2000:27-40. www.revue.forces.gc.ca/vo1/no1/ doc/27-40-eng.pdf accessed 7 September 2009.

5.

Ministry of Defence. The Aitken Report. An Investigation into Cases of Deliberate Abuse and Unlaw-ful Killing in Iraq in 2003 and 2004 http://www.mod.uk/NR/rdonlyres/7AC894D3-1430-4AD1-911F8210C3342CC5/0/aitken_rep.pdf accessed 7 September 2009

In the words of Dr Michael Ignatieff at the US Naval Academy:

6.

Tidwell A. When Trust Fails: The Blackhawk Incident. Australian Journal of Professional and Applied Ethics.1999,1(1)

Ethics is not an optional extra... it is the absolute core of what defines you as the warrior profession. It is ethical restraint which makes the distinction between a warrior and a barbarian…your life is one continuous set of ethical challenges8.

7.

‘Defending Australia in the Asia Pacific Century: Force 2030’, Department of Defence White Paper, Canberra, 2009.

8.

Ignatieff M. Virtual War: Ethical Challenges. Lecture to US Naval Academy January 12, 2005. http://www.usna.edu/Ethics/ Publications/IgnatieffPg1-24_Final.pdf accessed 8 Sep 09

Jamie Cullens Centre for Defence Leadership and Ethics Joint Education, Training and Warfare Command

Disclaimer: These views are those of the author and not the Department of Defence or the Australian Defence Force.



White Paper

The Defence White Paper and its Implications for Defence Health MAJGEN Jeffrey Rosenfeld, CAPT Mike O’Connor RANR

MAJGEN Jeffrey V. Rosenfeld is Surgeon General Defence Health Reserves. He joined the Army Reserve in 1984. He is Professor and Head of the Department of Surgery at Monash University and Director of Neurosurgery at the Alfred Hospital, Adjunct Professor, Centre for Military and Veterans’ Health and is the Chair, Editorial Board ‘ADF Health’. He has served on seven operational deployments for the ADF. CAPT Mike O’Connor AM RANR is Editor of ADF Health

ADF Health | Vol 10 No. 1 | 2009

Figure 1 Prime Minister Kevin Rudd, the Minister for Defence, Hon Joel Fitzgibbon MP, and the Chief of the Defence Force, Air Chief Marshal Angus Houston, AC, AFC launch the Defence White Paper 2009 onboard HMAS STUART with Service Chiefs and Defence Committee Members.

Introduction On 2 May 2009 the Defence White Paper 2009 (Defending Australia in the Asia Pacific Century: Force 2030) was released by the Commonwealth Government on the deck of HMAS Stuart. The Defence White Paper (DWP) outlines Australian Government defence policy for the next 20 years. It will however be revised every subsequent 5 years in the light of a preceding formal risk assessment, force structure review and independent audit of Defence enterprise1.The first white paper was motivated by the need to develop a concept of the defence of Australia in the post-Vietnam War era. It was delivered in 19762. This was followed by 3 further defence white papers in 1987, 1994 and 2000. The last of these followed the intervention in Timor L’Este.

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The Purpose of Defence White Papers According to Leece there are four reasons behind releasing a public statement of Australian Government policy on defence: 3

1. To enlist bipartisan parliamentary support and community support for its initiatives. 2. To galvanise support for its contents within and without the ADF including relevant government departments and civilian contractors. A vast team of personnel need to comprehensively understand the policy and their role in achieving its goals. 3. To declare Australia’s defence intentions to our regional and more distant neighbours in an effort to develop ‘mutual confidence and collective security’ in the Asia-Pacific region. 4. To clearly enunciate Australia’s defence stance towards potential aggressors. It acts as a deterrent in its own right. The present DWP, under the oversight of the National Security Committee of Cabinet, has had the benefit of wide preliminary consultation including supervision by a ministerial advisory panel, an effective process of public consultation4 and strong support by the Chiefs of Staff Committee (COSC).

Major Initiatives in the Defence White Paper 2009 Australia’s defence strategy has several clear priorities: i. To deter and defeat armed attacks on Australia ii. To contribute to the stability and security in the South Pacific and Timor L’Este region iii. To contribute to military contingencies in the AsiaPacific region as well as meeting our alliance obligations to the United States of America. iv. To contribute to military contingencies in the rest of the world in support of the international community.5 The DWP has acknowledged the need for effective maritime defence as a means of achieving the first of these aims. Navy will have its capability enhanced by the acquisition of 12 new Future class conventionally powered submarines, 3 new air warfare destroyers, 8 antisubmarine frigates, 2 landing helicopter dock (LHD) ships including expanded Primary Casualty Receiving Facilities (PCRF) or Maritime Role 2E (MR2E) which will be considerably larger than those on HMAS KANIMBLA & MANOORA, 1 strategic sealift ship, 6 heavy landing craft, 1 replenishment and logistic support ship, 20 offshore combatant vessels 24 naval combat helicopters and six MRH-90 helicopters. All these new acquisitions will require an additional 700 naval personnel. Army will have a combined strength of 10 battalion-sized “battlegroups’ consisting of three 4,000-strong combat brigades as well as two additional infantry battalions and five combat support units. It will be reequipped with 1100 new combat vehicles with enhanced protection and firepower. Thirty MRH90 helicopters will replace the Army’s Blackhawk fleet and seven Chinook medium–lift helicopters (CH47F) will improve troop

mobility. Army communications systems as well as command and control systems are scheduled for major upgrades. The air defence system will be enhanced by replacement of the current RBS-70 missile system. There will be a significant improvement to soldiers’ personal protective equipment for dismounted close combat. An implementation plan to rebalance the mix of full time and part time soldiers, which is required to meet the DWP’s objectives, will be developed by the end of 2009. Airforce will benefit from the purchase of 100 F-35 Lightning II Joint Strike Fighter aircraft as well as 24 F/A 18 Block II Super Hornet jets. Air to air refuelling capability will be enhanced by five new KC-30A Multi-Role Tanker Transports and surveillance, command and control functions will be improved with the purchase of six Wedgetail Airborne Early Warning and Control aircraft. A fleet of eight new Maritime Patrol aircraft will replace the current AP-3C Orions and they will be complemented by seven high altitude Uninhabited Aerial Vehicles. The existing fleet of C-130J Hercules aircraft will be expanded to 14 by the purchase of two new aircraft and the Caribou aircraft will be replaced by 10 new tactical battlefield airlifters. Airforce will receive new systems to enhance air surveillance, air traffic control, navigation and communication. This is a very positive outcome for the ADF and for the defence of Australia over the medium to long term. It has also been delivered in a climate of fiscal challenge.

Funding DWP acquisitions: the Strategic Reform Program (SRP) The Strategic Reform Program accompanies the White Paper. It is a far-reaching program which will develop fundamental reforms in the way Defence carries out its activities.It requires efficiencies in all aspects of Defence business and reorganisation and restructuring of the Defence organisation as a whole.This process is now well underway and will certainly have a major effect on the delivery of Health Services in the ADF. Until 2017 /18 the Defence Budget will continue to increase in real terms by 3 per cent per annum 6.Thereafter until 2030 it will increase by 2.2 per cent annually. The shortfall in expenditure on new acquisitions is to be provided by planned savings under the Strategic Reform Program of $20 billion over the next 10 years. The accountability for Defence expenditure is to be carefully scrutinised. Almost every aspect of Defence is to be analysed for potential savings. However the DWP makes it clear that operational capability and quality and safety in support areas is not to be compromised. Improving efficiency, eliminating waste and increasing productivity are the key strategies for cost reductions7. All members of Defence are responsible and accountable for implementing the SRP. Joint Health Command and Defence Health are actively engaged in the SRP process. There is significant scope to improve health service delivery efficiencies while providing best practice and quality care

Implications for ADF Reservists The philosophy of Reserve service is changing from that of a contingency resource to a fully integrated component of the total workforce of the ADF.This change has been referred to as the difference between a “just in case” to a “just in time” concept 8. The increasing demand for rapid deployment of

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Reserves using increasingly complex systems and equipment will mean that they will need enhanced levels of training 9 .Once implemented; this will ensure that Reservists are better integrated into all three Services as well as into joint operations and those with our Coalition partners. In addition there will be increased expectations on Reservists to make themselves available for voluntary service in support the ADF’s operational capability. ‘Operational deployment at some stage of an individual’s career will be expected as a naturalconsequence of part-time service in the ADF 10’ Where this is most likely to occur is in prolonged deployments (‘the long war’) requiring regular rotations of personnel. The longer lead times of replacement rotations provide distinct advantages to part-time ADF members. It is likely that the trend for Reservists to move between fulltime and part- time service will increase. Such transitions might occur several times during their professional lives. This varied experience is viewed as beneficial for the ADF and industry. MAJGEN Melick, the Head of the ADF Reserves, refers to a new ‘whole- of-career’ employment approach whereby the ADF provides a more flexible range of opportunities to personnel in order to become a ‘competitive employer of choice in the wider marketplace’11. Clearly the Reserves are already contributing significantly to the ADF full time workforce: 1700 man years in the last financial year (FY). Over the past 3 years 7000 Reserves have served on domestic and off-shore operations and in the 2007/8 financial year 8,400 Reservists have each delivered more than 50 days of part time service12.In the Navy Health Service Reservists on Continuous Full Time Service (CFTS) render an average of 5% of PNF workforce requirements (with up to 10% being provided in some categories). Since the beginning of the Financial Year (FY) 2009/2010, 156 Reserve Health Service Personnel have been posted to work a total of 2414 days over the FY. By the end of the year, it is expected that Reserve Health Service Personnel will contribute over 5000 days during the FY. This represents almost 10% of the total health service provided by Navy. It is intended that the ADF recruit more women and citizens from a greater variety of ethnic groups including indigenous Australians. This will to better reflect the diversity of Australian society.

Implications for Defence Health In a document as far reaching as the DWP it is hardly surprising that Defence Health details are not extensive13. However, well before the release of the DWP, in March 2008, the current Commander of Joint Health Command, was commissioned to undertake a review of Australian Defence Health Services. The Alexander Report , focussed on the restructure of Defence Health Services Division to develop a Joint Health Command (JHC).It included ten major recommendations for reform and was accepted by the Chiefs of Staff Committee (COSC) in August 2008.Four of those recommendations have already been implemented. These include the appointment of a Commander of Joint Health Command (CJHC) and Surgeon General ADF (MAJGEN Paul Alexander), the transfer of Joint Health Command (JHC) to the Vice Chief of the Defence ADF Health | Vol 10 No. 1 | 2009

Force (VCDF) Group, the appointment of a third one star officer (RAAF) to JHC and the establishment of Service Level agreements. The remaining six recommendations are in the process of implementation: • The appointment of Regional Health Directors. • The centralisation and consolidation of Garrison Health Support. • The transfer of authority and responsibility for Defence Health Materiel (equipment, pharmaceutical supplies etc) to CJHC. • The introduction of electronic health records (eHealth) for ADF members. • A reorganisation of Area Health Services. • A revision of operational health support (Op Concept or OPCON) .This has been informed by the changing scope of injuries and illness encountered in recent deployments. It forms part of the JP 2060 and seeks to enhance the Australian Defence Force’s deployable health capability to provide medical and dental care and services for deployed forces. JP2060 is a joint project which aims to provide equipment and systems that will enhance an ADF-wide capability. This involves discrete critical elements within each of Army, Navy and Air Force. New alliances with State government health services and that from private institutions are envisaged such as that already in place at the Navy ward within St Vincent’s Hospital in Sydney. This model will allow Defence Health personnel to train and work within major university teaching hospitals. It will enhance research collaborations and multidisciplinary care of ADF personnel and will aid the recruitment of specialists and other health professionals into the ADF. Selected specialist reservists will form teams within these major hospitals and will be available to deploy on ADF operations at short notice thus improving the Defence Health capability. There is a commitment in the DWP to improve the delivery of mental health services by implementing the Dunt Review’s recommendations (see editorial comment in Orme in this edition).This will involve ‘workforce changes to ensure that the ADF has an effective structure to deliver physical and mental health initiatives and services’. Recruitment of additional psychologists is already underway. Eighty three million dollars will be spent over four years to improve mental health services in the ADF. Clearly this is a major and comprehensive reform program.It is proceeding rapidly and will produce efficient and effective health support and health capability for the ADF. Along with the reforms in mental health recommended by the Dunt Report, the establishment of strategic alliances with major civilian teaching hospitals, and a re-invigoration of the Reserve health force we are on the verge of a complete restructure which aligns Defence Health very strongly to the SRP. Members of the Joint Health Command and health professionals throughout the ADF will continue to be challenged by this exciting and rapidly changing environment. In particular all ADF health

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professionals have a part to play in delivering on these reforms. They must at the same time maintain excellent health care throughout the ADF. The Defence White Paper, SRP and JHC Reform initiatives of the Alexander Review are all key components in a revitalised Defence Health Service. Twenty billion dollars of savings are expected from the Strategic Reform Program and they will be achieved by improving Defence accountability, planning and productivity. Those savings are crucial to the ability of Government to finance the acquisitions forecast in the Defence White Paper.

Concluding Remarks The DWP is fundamentally a blueprint for a highly efficient Australian Defence Force equipped with the most modern armament and better able to respond to threats to our own security as well as that of our regional neighbours and distant allies. By improving efficiency and eliminating waste, by better utilising our current resources including Reservists, the ADF will emerge from the Strategic Reform Program mutatis mutandis as a leaner more cost effective and powerful potential deterrent. In Defence Health the DWP offers improvements in mental health care. Other innovations such as E-health and promising partnerships with civilian institutions will flow from the Alexander Review. The restructure of Defence Health will ensure that health dollars are spent on our core business: the health of Defence members.

Acknowledgment BRIG David Leece PSM, RFD, ED (Ret’d): Editor, United Service provided valuable assistance.

References 1.

Leece DR, ‘Australia’s Defence White Paper 2009’ Journal of the United Services 2009;60:5-9

2.

Commonwealth of Australia. Australian Defence.1976

3.

Id

4.

Ibid

5.

Leece DR, ‘Australia’s Defence White Paper 2009’ United Service 2009;60:5-9

6.

Leece DR, ‘Australia’s Defence White Paper 2009’ United Service 2009;60:5-9

7.

Melick AG, ‘Defence White Paper 2009: what does it mean for the Australian Defence Force Reserves?’ United Service 2009 60:11-13.

8.

Melick AG, ‘Defence White Paper 2009: what does it mean for the Australian Defence Force Reserves?’ United Service 2009; 60:11-13.

9.

Id

10. Id at 13 11. Melick AG, ‘Defence White Paper 2009: what does it mean for the Australian Defence Force Reserves?’ United Service 2009 60:11-13. At 11 12. Id at 12 13. ‘Defending Australia in the Asia Pacific Century: Force 2030’, Department of Defence White Paper, Canberra, 2009 at 160. http://www.defence.gov.au/whitepaper/docs/defence_white_ paper_2009.pdf accessed 5 Sep 09

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Based on surgeon input and feedback, KCI Medical recently launched the ABThera™ Open Abdomen (OA) NPT System which is its latest innovation engineered specifically for the management of open abdomen to help achieve primary fascial closure. The ABThera™ Open Abdomen (OA) NPT System is a temporary abdominal closure system that helps surgeons take control early when managing a challenging open abdomen, it is engineered for fast application and ease of use thus saving valuable time in the O.R. The ABThera™ Open Abdomen (OA) NPT System Utilises continuous negative pressure, removes fluid and helps reduce bowel edema, helping achieve primary fascial closure. To assist clinicians, KCI has released a new publication on U.S. clinical guidelines for the management of the open abdomen utilizing KCI’s active abdominal management systems. The clinical guidelines, developed by an international expert consensus group of 13 surgeons, provide a novel classification system and recommendations on the practical application of the new product. Recently, KCI Medical highlighted this new addition to the KCI Negative Pressure Technology Platform (NPTP) at a sponsored symposium by the company on October 2nd at the 68th Annual Meeting of the American Association for the Surgery of Trauma, the preeminent annual event for Trauma surgery, in Pittsburgh. The symposium, titled “Latest Perspectives in Management of the Open Abdomen,” was driven by a renounced international panel of experts who discussed the substantial challenges in managing open abdomen patients. The ABThera™ Open Abdomen (OA) NPT System is now available in Australia and will feature at all major conferences in early 2010. To inquire about product availability and clinical evidence of the use of NPWT in military settings for a reliable early primary closure of war injuries please send an email to MarketingAU@kci-medical.com or contact KCI’s Customer Service at 1300 KCI VAC (524 822) n



Simulation Training

Simulation training for ADF surgical and intensive care teams: a pilot study J. Vassiliadis1, R. Mallett3, S. O’Regan1, K. Harrison4, A. Rehak1, S.J. Neuhaus2

Authors LCDR John Vassiliadis MBBS, FACEM is Deputy Director of the Sydney Clinical Skills and Simulation Centre and Staff Specialist in the Emergency Department at Royal North Shore Hospital in Sydney. He has a special interest in trauma and disaster medicine and is an EMST instructor. LTCOL Richard Mallet is an instructor at the Australian Command and Staff College, Weston Creek, ACT. He is a science graduate with graduate diplomas in management and logistics management. FLTLT Stephanie O’Regan has been the Simulation Coordinator at Royal North Shore Hospital since 2004.She has been a nursing officer in emergency medicine for over 20 years and holds Masters Degrees in Health Services Management and Health Science (Education).

Dr Ken Harrison FANZCA is a specialist anaesthetist who is Manager, Education and Disasters NSW Careflight as well as a Visiting Anaesthetist at Liverpool Hospital and a Staff Anaesthetist at Westmead Hospital in Sydney. He is Deputy Director of MRU Ambulance Service NSW.His interests are in trauma, disaster medicine and education. Dr Adam Rehak FANZCA is a specialist anaesthetist and Senior Simulation Instructor at the Sydney Clinical Skills and Simulation Centre, Royal North Shore Hospital, Sydney.

Colonel Susan Neuhaus enlisted into the Australian Regular Army in 1987 and is currently a Reserve General Surgeon and Senior Advisor Health, HQ 17 CSS Brigade. She has served in Cambodia, Bougainville and Afghanistan, is a graduate of Australian Command and Staff College (Reserve), past Commanding Officer of the 3rd Health Support Battalion and previous Editor of ADF Health. She was awarded the Conspicuous Service Cross in 2009.

1.

Sydney Clinical Skills and Simulation Centre John Vassiliadis MBBS FACEM, Deputy Director, Simulation Clinical Lecturer, Northern Clinical School, University of Sydney LCDR RANR

Stephanie O’Regan RN, BNurs, MHSM, MHSc (Ed), Simulation Coordinator, FLTLT RAAF

Adam Rehak, MBBS FANZCA, Senior Instructor

2.

Colonel Susan J Neuhaus MBBS, PhD, FRACS, CSC HQ 17 CSS BDE, Randwick Barracks, RANDWICK, NSW, Clinical Associate Professor of Surgery, University of Adelaide, Adelaide, South Australia

3.

Lieutenant Colonel Richard Mallet, Bsc, Grad Dip Log Mangt, Grade Dip Mangt. Instructor, Australian Command and Staff College, Weston Creek, ACT

4.

Ken Harrison MBBS FANZCA, Manager, Education and Disasters Careflight.

Abstract This paper describes a pilot program to develop pre deployment simulation training for health personnel including surgeons, intensivists, nurses and medics. The initiative was prompted by the need to provide realistic wartime surgical experiences and to develop pre-deployment teamwork. Success was measured in terms of participants’ satisfaction and the observations of team performance by the training faculty.

Introduction Medical simulation in training is accepted practice in many areas of health and it has been demonstrated that group behaviour and improvement in team performance occurs with training.1-11 Difficulty in obtaining realistic team-based medical experience prior to specialist health teams arriving in a battlefield environment makes medical simulation an attractive option for military training.

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Military medicine faces similar challenges in all countries: to train medical personnel in peace for the realities of war or conflict. In Australia what corporate experience there is, resides in civilian practice and with Australian Defence Force (ADF) health specialists, who are almost exclusively reservists and who volunteer at times of need. As a result, groups of people who may have never worked together are placed in situations where they are required to work as an effective team in a very short period of time and under difficult and challenging circumstances. Sub-specialisation in medicine in Australia means that there are few specialised ‘trauma surgeons’ who routinely performs resuscitative or damage control surgery. Combat injury patterns from current operations are different from most civilian trauma. Combat trauma is characterised by multisystem blast, burns or ballistic injuries. These are complex injuries and successful outcomes require collaborative and multidisciplinary management. The training gap both in skills and team-based training is significant. As Moses et al state: ‘Military medical personnel have almost no chance during peacetime to practice battlefield trauma care skills… With some of today’s training methods disappearing the challenge of providing both initial and sustainment training for medical personnel is becoming insurmountable’12. Simulation can provide a risk-free simulated learning environment where medical teams train across a range of medical procedures including trauma surgery. These ‘hands-on’ training opportunities in a simulated environment help teams to ‘train in peace as we would practise in war’2. The military environment is a complex and dynamic working environment in which crises develop both on the battlefield and in the operating/medical theatre. These may lead to danger or adverse outcomes – both to the medical personnel and to their patients. Once a crisis has developed, sound medical knowledge or military protocols may not be enough to resolve it. Military medical personnel must be equipped to recognise, avert or manage impending crises. This requires training in Crisis Resource Management (CRM) 1. Although the relevance of such training models is increasingly recognised by the health community13, to our knowledge no formalised curriculum or course exists in the ADF that provide these skills to senior specialist clinicians. However, sophisticated combat medical simulation centres do exist in the US, Israel and elsewhere. Parallels exist with the airline industry which also functions in a high risk environment. Research in that industry has identified that most airline disasters are not due to equipment failure, but due to human error and failures in decision making, communication and leadership14. As a result, a flight simulation- based curriculum called Crew Resource Management was developed to teach the necessary teamwork and leadership skills15. Crew Resource Management training is a requirement for all Australian and US flight crews. Medical Crisis Resource Management (CRM) has developed out of the principles of aviation CRM1. Medical CRM was identified as a core requirement of the mission specific training for specialist ADF surgical and intensive care teams deploying into a multinational facility within the Middle East Area of Operations. This paper addresses the ADF Health | Vol 10 No. 1 | 2009

recent simulation experience used to enhance the operational readiness of Surgical and Intensive Care teams (AUSMTF-1 and 3) prior to their deployments to Afghanistan.

Methods Study Design and Population. This report is based on a follow-up survey given to participants after completing the Military Emergency Crisis Management (MECM) course at the Sydney Clinical Skills and Simulation Centre (SCSSC), Royal North Shore Hospital. The ADF personnel who participated in the two courses included twelve specialists (made up of anaesthetists, intensivists and surgeons), seven medics and ten nurses. All the specialists were reservists. All medics and some nurses were full time members of the ADF. Each of them gave informed consent prior to participating and the study was granted ethics approval by the Northern Sydney Area Health Service. Overview of the MECM Course. All the participants were provided with pre-reading that outlined theories of communication, team leadership, teamwork, graded assertiveness and CRM. This reflected the brief given to the course director, in regards to the AUSMTF needs and the construct of the mission specific training. The course began with a brief introduction to the background and goals of MECM. The course director emphasised to the participants that the goal of MECM was not to evaluate each participant’s performance but to focus on understanding the key CRM principles (Table 1) and the human factor principles of leadership, teamwork, decision making and error identification and prevention. Table 1. Crisis Resource Management Principles 1. Know your environment 2. Anticipate and plan 3. Call for help appropriately 4. Prioritise 5. Allocate attention wisely and use all available information 6. Distribute workload and use all available resources 7. Communicate effectively

The participants were introduced to a structured approach for thinking when confronted with any emergency. This included a risk/benefit evaluation of the plan of management and developing a contingency plan. In order to emphasize the applicability and importance of the CRM principles (Table 1), the participants viewed an 8 minute video of a flight simulator re-enactment of an actual commercial airline crash. It contained examples of simple avoidable errors, made by the pilots and an air traffic controller which led to the disaster. The course director then used the video as a basis to discuss and explore CRM, team work and error. The participants were subsequently orientated to their simulated field hospital and mannequin simulators (METI High Fidelity Patient Simulator and Laerdal Simman).

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In keeping with adult learning principles, a multimodal instructional approach was employed. The group took part in a desk activity exploring the issues of managing a mass casualty incident. This was followed by six high fidelity simulated case based scenarios. The participants took part in the scenarios in teams of four or five, assuming their usual roles in a deployed environment. (Fig 1 - 3). One of the nurses in each of the scenarios was a faculty member and wore a headset to allow private communication with the scenario director in the control room. (Fig 4).This ensured that each case met its planned learning objectives. Groups who were not involved remained in a separate room to observe via a video link. The scenarios were structured to simulate the unique circumstances of the combat environment, which included a realistic laparotomy model, which required the surgeon to perform 4-quadrant packing and control ongoing bleeding. This proved to be a good model for reinforcing the principles of damage control surgery and ensuring that the team were each aware of their competing needs and priorities. The director, a trained facilitator, concluded each scenario when the objectives of the scenario had been met and there was sufficient material for constructive debriefing. Participants, observers and instructors then debriefed each scenario together for about 20 minutes. The debriefing had several aims: to discuss the clinical, CRM and human factor issues raised by the scenarios, and then to consider how the lessons learned might be translated into their clinical practice. Data Analysis. At the conclusion of the MECM course all the participants completed a post course evaluation. The evaluation consisted of a 5-point Likert Scale ranging from a score of one (strongly disagree) to five (strongly agree). The mean and standard deviation were calculated for each response.

Results Twelve ADF Reserve Medical Specialists, 10 nurses and seven medics took part in the two courses. The results of the post course appraisal that were completed by the participants are summarized in Table 2. The participants considered the course very useful pre-deployment training: it provided teamwork opportunities and allowed them to understand each other’s roles and capabilities. They particularly valued the realism of the clinical scenarios. The participants appreciated the chance to debrief and discuss the challenges of their future deployment. Table 2. Results of the post course appraisal of MECM (Likert Scale: 1 – Strongly disagree to 5 – Strongly Agree) Question

Response (mean ± SD)

The course was well organised

4.80 ± 0.41

The course was relevant for my practice

4.60 ± 0.50

The course was pitched at the right level

4.67 ± 0.48

The course satisfied my expectations

4.70 ± 0.47

The instructors taught the course well

4.87 ± 0.35

I would recommend this course to my colleagues

4.80 ± 0.41

The course increased my level of competency

4.63 ± 0.56

The course increased my ability to work in a team

4.65 ± 0.54

I found the presentations useful

3.63 ± 0.56

I found the familiarisation with the simulator environment useful

3.53 ± 0.63

I found the table top exercise useful

3.53 ±0.73

I found the scenarios useful

3.93 ± 0.25

I found the debriefing sessions useful

3.83 ± 0.38

The course objectives on teamwork, leadership, communication and human error were met

4.66 ± 0.48

I feel more confident managing trauma in a military environment

4.59 ± 0.63

Discussion Deploying medical personnel have a crucial need for crisis management team training. Currently no formal training exists to prepare health personnel for the potential stress of the deployed military environment and mission. The MECM course allowed participants to develop skills in communication, error recognition and prevention, teamwork and graded assertiveness in a safe learning environment. They practised key skills in highly realistic simulated clinical scenarios. This led to productive, frank discussion and debriefings. Team performance improved successively over the course of the six simulated scenarios. Attitudes towards individual and team performance became more positive during the course of the training. By the end of the course the participants felt more competent in responding to medical emergencies and also more comfortable with their co-participants. These findings are consistent with Chen and Kanfer’s16 multilevel team model . Those researchers claim that effective team performance is more than ‘throwing a group of people together with a common purpose’: each team member must understand their own, and others’ roles in order for the process to be effective. The MECM pre deployment courses aimed to expand on this model and allow the participants to experience the value of scripted roles. It was designed to facilitate an understanding of the roles, responsibilities and skills of their colleagues and the impact of this on improving team performance and outcomes. It achieved those goals. The greater understanding within each team helped motivate and empower them and positively influenced their attitude to successfully respond to a medical/ surgical emergency. Medical simulation allows participants to experience team training in procedural and communication skills. This MECM course provided fully immersed medical simulation. The focus was not on medical procedures or knowledge, but rather on establishing a level of commitment and collective experience in each team. This enhanced their ability to make complex management decisions. The two teams were highly trained and

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experienced civilian professionals who were about to deploy. Their deployment would be to an unfamiliar environment and setting and, in a multinational environment that could challenge their perceived roles, responsibilities and clinical management practices. High fidelity simulation allowed us to create scenarios which would be considered unique in civilian practice .They would be impossible to recreate without simulation. The participants had the opportunity to learn by experience17 and reflection18, both are key components of adult learning theory19 .They are also crucial for effective teamwork in challenging deployments. Learning occurs in a simulated environment which imitates, but does not duplicate reality. Participants are afforded opportunities to try out new strategies without risking adverse patient outcomes. They can also discuss outcomes in a safe, ‘no blame’ environment.

Fig 1. Anaesthetic and surgical teams preparing the manikin for surgery

Few opportunities exist in a military environment for health personnel to formally debrief after a clinical case. Collegiate discussion about the conduct, management and potential for improved performance results in better clinical outcomes6. The ability of a military health specialist to deliver ‘best practice’, often under very difficult circumstances20, depends not only on their technical skill, but good teamwork. Simulation training assists this process21. One goal for the course was to convince participants of the value of a ‘team time out’. This meant a preliminary brief discussion with all the team members about the proposed clinical approach and each person’s role .In civilian practice, team members often tend to work in isolation and assume that other team members understand their expected contribution. We placed value on good communication, preparation and planning-qualities which would be of particular value to medical teams in a deployed environment. In a multinational environment using unfamiliar equipment and different cultural expectations, clear communication becomes even more vital.

Fig 2. Manikin moulaged to simulate severe burns

The command and leadership elements of the group witnessed how the team established its working dynamic and how it functioned under simulated stress. This provided valuable information and insight into further training and skills that may be required before a team is deployed. Individuals should not be chosen for remediation unless a particular behaviour or management concept is deemed unacceptable or dangerous. When necessary, this should always be done privately. The results of this pilot study show that MECM was well accepted by the participants and indicated that this type of training was likely to benefit pre deployment medical teams.

Limitations Despite the small size of this study, we believe the positive response to crisis management team training in the MECM course warrants further investigations at our institution, as well as others. Our study did not evaluate long term crisis management knowledge, skills and attitude retention after training. Further study needs to be address how frequently medical teams should train in MECM and whether the lessons learnt in the simulated environment are transferable to the military environment. Most of the participants had little prior exposure to high fidelity simulation. Future studies would need to investigate how the learning experience for participants is affected as their familiarity with simulation is increased. ADF Health | Vol 10 No. 1 | 2009

Fig 3. Surgical team performing damage control surgery on simulated bleeding abdomen

Conclusions The positive results from this initiative were encouraging. Given the proven success of other simulation- based team training courses in the medical and aviation industries, further development and investigation of simulation based crisis management training for pre deployment military medical teams is indicated. The MECM course is ideally suited to meet the ADF’s needs because it delivers realistic and relevant training. Simulation

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is increasingly b e i n g incorporated into lower order health training (e.g. team based resuscitation) However the needs of a specialised surgical and intensive care health team are qualitatively different, with less emphasis needed on technical competency and more on nontechnical and communication Fig 1. Confederate member of faculty wired up to issues. The communicate with the course director MECM training has demonstrated a new way of delivering operationallyfocused health training to military specialist health teams. The training is cost effective and can potentially increase the experience and confidence of specialist health teams in dealing with complex combat environments.

Acknowledgements The authors would like to acknowledge the support of HQ 17th Combat Service Support Brigade and Colonel Georgeina Whelan, Command Health Officer, HQ Forces Command for their support.

References 1.

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Howard S, Gaba D, Fish K, Yang G, Sarnquist F. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992; 63: 763-770. Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomised controlled trial. Obstet Gynecol 2007; 109:48-55. Dunn E, Mills PD, Neily J, et al. Medical team training: applying crew resource management in the veterans’ health administration. Jt Comm J Qual Patient Saf 2007; 33:317-325. Morey JC, Simon R, Jay GD et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the Medteams project. Health Ser Res 2002; 37: 1553 – 1581. Thomas EJ, Taggart B, Crandell S et al. Teaching teamwork during the Neonatal Resuscitation Program: a randomised trial. J Perinatol 2007; 27:409-414. Robertson B, Schumacher L, Gosman G et al. Simulation – Based Crisis Team Training for Multidisciplinary Obstetric Providers. Sim Healthcare 2009; 4:77-83. DeVita M, Schaefer J, Lutz J, et al. Improving medical emergency team (MET) performance using a novel curriculum and computerised patient simulator. Qual Saf Health Care 2005; 14:326-331. Gaba DM, Howard SK, Fish KJ, et al. Simulation based training in Anaesthesia Crisis Resource Management (ACRM): a decade of experience. Simul Gaming 2001; 32: 175 -193. Blum RH, Raemer DB, Carroll JS, et al. A method for measuring the effectiveness of simulation-based team training for improving communication skills. Anesth Analg 2005; 100:1375-1380. Kim J, Neilipovitz D, Cardinal P et al. A pilot study using high fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine and high fidelity simulation, and Crew Resource Management I study. Crit Care Med 2006; 34:2167-2174. Morgan PJ, Pittini R, Regehr G, et al. Evaluating teamwork in a simulated obstetric environment. Anesthesiology 2007; 106:907-915. General Accounting Office in Moses G, Magee JH, Bauer JJ, Leitch R. Military medical modelling and simulation in the 21st Century. Stud Health Technol Inform 2001;81:322-8. Flin R, Yule S. Patterson Brown S, Rowley D, Maran N. The NonTechnical skills for Surgeons (NOTSS) System Handbook, v 1.2 University of Aberdeen and Royal College of Surgeons of Edinburgh. Helmreich R, Merritt A, Wilhelm J. The Evolution of Crew Resource Management Training in Commercial Aviation. Int J Aviation Psych 1999; 9: 19-32. Wiener EL, Kanki BG, Helmreich RL. Cockpit Resource Management. New York: Academic Press, 1993 Chen G, Kanfer R. Towards a systems theory of motivated behaviour in work teams. In: Shaw B, ed.: Research in Organizational Behavior: An Annual Series of Analytical Essays and Critical Reviews. Vol. 27. New York: Elsevier; 2006: pp. 223-267. Dewey J. Thinking in education. In: Barnes LB, Christensen CR, Hansen AJ, eds. Teaching and the Case Method. 3rd ed. Boston, Mass: Harvard Business School Press; 1994, pp.9-14 Schon DA. The Reflective Practitioner: How Professionals Think in Action. New York, NY: Bantam Books; 1983 1. Bloom B. S. (1956). Taxonomy of Educational Objectives, Handbook I: The Cognitive Domain. New York: David McKay Co Inc. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? M J Shapiro1, J C Morey3, S D Small2, V Langford3, C J Kaylor, L Jagminas1, S Suner1, M L Salisbury3, R Simon4, G D Jay1 Quality and Safety in Health Care 2004;13:417-421. Error Reduction and Performance Improvement in the Emergency Department through Formal Teamwork Training: Evaluation Results of the MedTeams Project. Morey, John C.; Simon, Robert; Jay, Gregory D.; Wears, Robert L.; Salisbury, Mary; Dukes, Kimberly A.; Berns, Scott D. Quality of Care Health Services Research. 37(6):1553-1581, December 2002.



Mental Health Reform

The Mental Health Reform Health Process (Dunt Report): A Support System for ADF Personnel LTCOL Stephanie Hodson, Lyndall Moore and MAJ John McGrogan

Editorial Comment Lieutenant Colonel S. E. Hodson, CSC. BPsych (Hons). PhD.

LTCOL Stephanie Hodson graduated from James Cook University in Townsville with a BPsych (Hons) in 1990 and joined the Army in August 1991. She had had a range of posting across Australia including recruiting, research and counselling duties. LTCOL Hodson completed her doctoral studies investigating the longitudinal psychological effects of operational deployment to Rwanda in 2002 and in 2003 completed Command and Staff College. In 2006 she assumed command of the 1st Psychology Unit and was responsible for all land base psychology support to ADF operations. While CO 1 Psych she had the opportunity to deploy to both the Middle East Area of Operations and Timor L’Este. For her work during this posting she was awarded the Conspicuous Service Cross in the 2009 Australia Day Honours List, “For outstanding achievement as the Commanding Officer, 1st Psychology Unit”. In the first half of 2008, LTCOL Hodson worked as the SO1 Retention Research in the Directorate of Strategic Personnel Policy and Research. In mid 2008 however, at the request of Joint Health Command, she accepted the position of Director of Mental Health for the ADF. As the Director of Mental Health she has coordinated the ministerially directed independent review of ADF mental health and is part of the team coordinating the Defence response to the recommendations. Lyndall Moore RN BN completed her training as a Registered Nurse in 1989 and followed this with a Bachelor of Nursing in 1992. She specialised in critical care nursing with a particular focus on Intensive Care. In 1993 she joined the RAAF as Nursing Officer and completed 7 years of service including a deployment to Rwanda in 1995. Following her discharge from the RAAF in 2000, she worked in a variety of nursing management roles, in a number of wards and high dependency units in rural areas around Australia in both the private and public health care sectors. Lyndall has worked internationally, with a nine month stint as the after- hours supervisor for a 30 bed facility in remote Canada which provide a unique insight into Canadian health issues. She has recently moved away from clinical focus and is currently the Chief of Staff to Commander Joint Health/Surgeon General ADF. MAJ McGrogan was appointed to the Army in 1996. His postings have included recruiting, training establishments, staff appointments, and in deployable elements. The focus of MAJ McGrogan’s career has been the provision of mainstream psychology support in a variety of environments, with an emphasis on the supervision of psychologists. MAJ McGrogan has deployed on operations to Bougainville, East Timor, and the Middle East.

Hodson et al have highlighted the far-reaching implications of the Dunt review into mental health. The ADF has responded positively by endorsing 49 of the 52 recommendations and has partially endorsed the remaining three of the Report’s recommendations and funded them as flagged by the Defence White Paper. This not only recognises the impact on the mental health of personnel resulting from the ADF’s increased and sustained operational tempo in recent years, but gives Joint Health Command a once in a generation opportunity to significantly enhance mental health services and resources for the future.

Abstract The Review of ADF Mental Health Services and Transition Through Discharge (Dunt Review) was initiated by the Ministers of Defence, Science and Personnel and Veterans’Affairs.The purpose was to provide an independent assessment of the current ADF models of mental health (MH) support, and the mechanisms of transition of those medically discharged with a mental health condition from the ADF to DVA. A key goal was to determine how adequately the mental health needs of serving, and transitioning ADF members were being met. Existing models of ADF mental health support were measured against best practice for clinical care and administrative support. The Dunt Report made significant recommendations for improving mental health services including enhancing the MH workforce, improving MH training , introducing preventative MH strategies as well as enhancing MH governance, policies ,research and surveillance. Rehabilitation and return to work practices were to be enhanced and a more seamless transition to civilian life for those ADF members with MH problems was to be arranged. Joint Health Command will engage with the families of affected ADF members to enhance their education and support. Facilities for MH care will also be improved to encourage better support for members and their families. The Dunt Report was delivered ahead of schedule in November 2008.

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L to R: LTCOL Stephanie Hodson, Professor David Dunt, Hon Warren Snowdon, Minister for Defence Science & Personnel, Hon Alan Griffin, Minister for Veteran’s Affairs, MAJGEN Paul Alexander.

Introduction The mental health support programs and services for Australian Defence Force (ADF) personnel represent one of the largest workplace mental health support systems in Australia. A major aim of the ADF Mental Health Strategy is to de-stigmatise mental illness and encourage ADF personnel to become engaged in their mental health. The ADF Mental Health Strategy was launched in 20021, 2 with initiatives including training programs for members to avoid alcohol abuse and prevent suicide, and interventions for personnel who have experienced traumatic events or incidents. The strategy also improved mental health policy and research on the mental health implication on ADF personnel, of operations. However, since the inception of the Mental Health Strategy, the operational tempo of the ADF has risen significantly, increasing the stresses and demands on personnel and on the organisation. For example, over the next twelve months, it is anticipated that up to 12,000 members will be in the operational deployment cycle – preparing for deployment, deploying, or transitioning home following deployment. Additionally, there are currently about 450 personnel regularly conducting border protection operations on mainland Australia and in our maritime and air approaches. This is a vastly different environment to that of 2000, when the ADF Mental Health Strategy was first introduced. It was in recognition of this changing environment that in 2008, the Government commissioned Professor David Dunt (University of Melbourne) to independently review and benchmark Defence mental health services. Professor Dunt’s final report, Review of Mental Health Care in the ADF and Transition through Discharge, was submitted on 4 February 2009. Prof Dunt consulted widely with ADF members, Defence civilians, and contractors. Interviews were conducted with senior ADF members including the Chief of the Defence Force, the Single Service Chiefs, as well as personnel in Joint Health Command. He visited eight bases around Australia (HMAS CERBERUS and HMAS KUTTABUL, Holsworthy (4RAR), Enoggera (particularly 2HSB), Lavarack ADF Health | Vol 10 No. 1 | 2009

Barracks and Kapooka, RAAF Townsville, and RAAF Wagga). These visits typically involved meetings with Commanding Officers and other senior staff, as well as senior health staff, junior officers, non commissioned officers and other ranks. Seventy-eight public submissions were also received from individuals and organisations. Prof Dunt generated common themes emerging from these interviews3 and followed them up by a significant literature review based on these themes. Professor Dunt described the original establishment of the ADF Mental Health Strategy “as far-sighted”, and held that the strategy currently compares favourably with mental health strategies in other Australian workplaces and military forces in other countries. In particular he acknowledged the enthusiasm and commitment of the personnel in the strategy. However, he identified that the Strategy’s roll-out was ‘patchy’ and that the Strategy currently faces significant challenges; most notably a lack of funding to adequately staff the programs that the Strategy aims to achieve4. The final report included fifty-two recommendations5; of which Defence wholly accepted forty nine, with the remaining three partially accepted. The report helped inform the 2009 Defence White Paper which recognised the importance of a greater commitment to improving the mental health of ADF personnel. Most importantly the White Paper allocated $83 million over the next three years to reform and enhance the ADF Mental Health Strategy6.

Major Recommendations of Dunt With endorsement and funding, Defence is now about to augment the Mental Health Strategy (MHS). The new goals for the MHS are: 1. Enhancing the mental health workforce. The first priority is to expand the mental health workforce within Joint Health Command by 50% within the next three years. This will significantly increase the personnel to deliver both primary health care and develop mental health promotion and prevention strategies.

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2. Improving mental health training. By increasing the mental health workforce the ADF will now have the personnel resources to ensure that a broad and comprehensive mental health literacy program can be delivered to serving personnel. Mental health literacy will ensure that service personnel know when, where and how to seek care. Furthermore, Defence is establishing an ADF Center of Mental Health which will become a centre of excellence for the training of military mental health professionals and health providers. 3. Prevention strategies. The ADF’s “BattleSMART”, Self Management and Resilience Training program is being developed to teach Commanders and individuals effective stress management and positive coping strategies. The program is designed to be built upon over the course of a person’s career, ensuring that mental health care becomes a core component of military training. 4. Improving mental health governance. The Mental Health Strategy will increase oversight of mental health services including the development of a comprehensive e-health data management and record keeping system. 5. Improving mental health policy. Breaking down stigma, by demonstrating that Defence’s goal is to treat and rehabilitate wherever possible, and that discharge on health grounds is the last resort 6. Enhanced research and surveillance. The effectiveness of psychological support throughout the deployment cycle

(including pre-deployment, during deployment, and postdeployment), and the roles of mental health screening, and the role of family and environmental support on resilience and mental health, will be examined 7. Rehabilitation and return to work programs. The ADF Rehabilitation Program will be enhanced through better case management by medical officers, and by improving the training of caseworkers in recognising and managing mental health issues. 8. Transition services. The transition from military to civilian life for individuals with mental health issues will be enhanced. 9. Families. In recognition that families of members are often the first to see changes in their mental health, Defence will engage families in ADF personnel mental health care. Joint Health Command will undertake a major project to inform and include families in mental health issues and to deliver more family-friendly practices. 10. Facilities. New and improved facilities for enhanced delivery of mental health services and easier access to care by ADF members and involvement by their families in support programs will be developed.

Concluding Remarks Significant challenges remain as this next generation of the Strategy is developed and implemented; the most notable being the current climate of reduced spending and increased efficiency. However the Dunt Review and the Defence White Paper have provided an important opportunity to improve the mental health system and services that support ADF members. The reform process will have to utilise mental health resources as efficiently as possible and have a process of continuous evaluation and improvement embedded within the framework. Furthermore, there will be challenges in restructuring the workforce, recruiting additional personnel and ensuring that all elements are trained in Defence-specific requirements. Professor Dunt highlighted the enthusiasm and commitment of ADF members in delivering mental health services and programs. This, along with the commitment and support from senior leadership in the Government and in Defence, provides the opportunities for real and significant development of the ADF Mental Health Strategy, and in Defence’s ability to more comprehensively support the mental health of its personnel through an increased and sustained operational tempo.

References 1.

Department of Defence (2002) ADF Mental Health Strategy, Department of Defence, Canberra. http://www.defence.gov.au/health/DMH/idmhs.htm accessed 5 Sep 09

2.

Department of Defence (2006) Mental Health Provision in the ADF, Defence Instruction General 16-24, Department of Defence, Canberra

3.

Dunt D, Review of Mental Health Care in the ADF and Transition through Discharge http://www.defence.gov.au/health/DMH/Review.htm accessed 5 October 2009

4.

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Id

6.

Defending Australia in the Asia Pacific Century: Force 2030, Department of Defence White Paper, Canberra, 2009. http://www.defence. gov.au/whitepaper/docs/defence_white_paper_2009.pdf accessed 5 October 2009


Reintegration

Return to Sender: Reintegration after Reservists Deploy Lieutenant Colonel Geoffrey J Orme RFD

Abstract Lieutenant Colonel Orme is a reservist and serves as the senior psychologist (SO1 Psychology) at Headquarters Second Division. He also works as a Project Officer at the Directorate of Mental Health on elements of the recent Dunt Review (2009), which relate to reservist’s mental health. He is undertaking a Doctor of Philosophy through the Centre of Military and Veteran’s Health (CMVH) at the Adelaide University node. He was the first reservist to lead Psych Support Teams on deployments to Bougainville, East Timor, Middle East (including Iraq) and Solomon Islands. He is in private practice in Sydney.

This paper outlines post deployment re-entry and reintegration challenges for reservists following a military deployment. The transformation of many militaries has highlighted the evolution of the role of reservists from a strategic reserve to an essential part of the total force. As a result of this change, reservists are now an integral component of military responses both overseas and domestically and rates of deployment are increasing. The risks to reservists are discussed and a potential solution outlined.

Correspondence: Postal: Headquarters Second Division, Pozieres Lines, Randwick Barracks, Avoca Street, Randwick NSW 2031. Email: geoff.orme@defence.gov.au

Faber AJ,Willerton E,Clymer SR,MacDermid SM,Weiss HM, ‘Ambiguous Absence,Ambiguous Presence: A Qualitative Study of Military Reserve Families in Wartime’J Fam Psych 2008;22: 222-230.

Editorial Comment This paper is a reminder of the mental health challenges which Reservists face after deployments. Great reliance is often placed on Reservist health personnel when health services deploy. As Orme points out, they have challenges that are different from permanent forces. When not deployed, many have little ongoing connection to the ADF and often have only family members or civilian employers to monitor their health and to support them. To access professional support requires a high level of insight, motivation and effort. Reservists are more likely to suffer in silence and fail to receive the treatment they require for conditions caused by their ADF service. They may feel abandoned by the ADF and may lose motivation for future ADF service. Neither is desirable given the ADF’s increasing reliance on reservists. In the light of the recent Dent review into mental health in the ADF, this paper is timely. Some of the cornerstone recommendations of the Dunt review are for enhanced prevention strategies, better mental health surveillance, enhanced rehabilitation and transition services, and greater involvement of families (who are often the forgotten primary source of support for reservists). The Dunt Review recommended expansion of the ADF mental health workforce. Orme’s paper, which highlights the particular issues of reintegration for Reservists, should be considered carefully as future ADF mental health policy, governance, and service delivery is planned.

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‘Reservists and their families are a unique sub-population within the armed forces and may encounter additional stressors related to deployment and reunion’.

Introduction The military transformation of reserve organisations from a strategic reserve to operational force has taken place within many militaries over the past few years 1. Reservists are now deployed on overseas military operations and contribution to capability exceeds fifteen percent (15%) of deployed personnel 3, which is similar to other nations such as USA, UK, Canada and NZ. The operational tempo in the ADF today is such that the reliance on Reservists to deliver capability and participate in operational deployments overseas and in continental Australia will remain high. Functions undertaken by reservists now extend beyond combat support to the full spectrum of military roles, including Special Forces, domestic security and humanitarian support. The ADF’s exclusive use of reservists in the Solomon Islands and their deployment to the recent devastating bush fires in Victoria provides testimony to the versatility of reservists. Reservists generally take great pride in balancing their civilian careers, family commitments and community responsibilities. Reservists have been described as ‘twice the citizen’, because of their commitment to both civilian and service careers.

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However, while reservists undertake similar roles to their permanent full-time counterparts, the process of reintegration to their civilian lives after the completion of their deployments is not well understood4. There are some significant differences between full-time and reserve personnel, and even between different services that may render the experiences learned from permanent personnel inadequate when applied to reservists. For example, there are significant differences between the three services with regard to the degree of exposure to fulltime service of their personnel. While the proportion of Navy and Air Force personnel who have had previous permanent service prior to reserve service is 85% and 95% respectively, only 20% of Army reservists have had previous service in the permanent forces5. Further, there are differences in the way that reservists are deployed. Research in the UK identified that although 65% of Regular personnel deploy with their parent unit, only 23% of Reservists did so11. Most reservists deploy individually or in small ‘capability bricks’ to bolster other units. While permanent personnel maintain their military support networks when they return from deployments (which is usually considered a vital buffer against post-deployment adjustment difficulties)10, reservists commonly lose the support networks that they established during deployments. Finally, for many reservists, a deployment may be a series of firsts; operational deployment, journey overseas, and lengthy absence from family, friends, studies and civilian work. With less engagement in stable social structures throughout the entire deployment cycles, from notification through to reintegration to ‘normal life’ after a deployment concludes, provides challenges and environments different to those experienced by permanent forces. While it is often assumed that reservists have the flexibility, patience, resilience and high levels of motivation to achieve this, reservist status has been identified as a risk factor in adjustment and post deployment well being6-9. Recent research in the UK with large numbers of reservists (Territorial Army) who deployed to Iraq from 2003 indicated a higher prevalence of ill-health outcomes compared to their regular counterparts. The researchers noted that the effect of deployment was different for reservists compared with regulars, and demonstrated evidence of a clinically and statistically significant negative effect on health in reservists12. Given the ADF’s increasing reliance on reservists, especially in the health services, it is in their interests to maintain visibility

Reserve Member Five Stakeholders

Deployed Formation

Provider Unit

Member (Reserve)

Civilian Employer/ Career

High Engagement Low Engagement

Family

Fig. 1 Stakeholders around a Reservist’s Deployment

of reservist’s wellbeing and to understand their experiences, to ensure their willingness for redeployment and continued readiness.

Understanding the experience of reservists Studies of the experiences of UK, US and Canadian reservists returning from active duty, indicate higher levels of adverse health outcomes and quality of life for reservists, compared to permanent forces. These studies attribute these differences to different levels of cohesion, social support and systematic follow-up in the post-deployment environment11,13-15,16. Reserve personnel may at times, return on their own with little in the way of formal homecoming activities and celebration of their achievements and the sacrifices made. The availability of peer (and military) social support, although important for post deployment adjustment19, 20, can be difficult or not available. While reservists may feel detached from the units they deployed with, their post-deployment environment (home, family, friends, civilian employment, etc) may have little to no comprehension of their deployment activities, adding to the experience of social isolation. For the permanent forces personnel, their families and friends may have time to adjust to previous and repeated deployments and view deployments as extensions of a member’s everyday career, rather than being something exceptional, as it is for reservists. The social network of a reservist returning from deployment may be complex than for a permanent member, as it includes not only their family and their unit, but may also include their civilian employer and their home unit (if deployed as an individual member). Finally, some entitlements and access to medical, family support and other services may also cease with the completion of the reservist’s full time continuous service contract; usually a few weeks after return. This limits the ability of services to monitor, support or intervene if required. For many reservists, out of sight means out of mind. It is usual that reservists exit the ‘military milieu’ and attendant support structures upon return and are, to a large extent, required to focus on the immediate needs of family and civilian life; including studies or career path. Close relationships developed on operations or during a deployment may cease on returning home with challenges associated with maintaining contact and ongoing support. This is exacerbated for regionally based personnel as well as specialist reservists who may not necessarily have strong links to a unit environment or regimental affiliations. This situation is also the case for family members and some civilian employers of reservists who may not be actively engaged with the military life of their family member or employee. Problems with deployment and repatriation are not confined to reservists, but can also include deployment and repatriation adjustments for their families and civilian employers due to absence, changes that occur during the deployment in absence of the other, changes in roles and expectations of the other, and adjustment to reunion. Returning to civilian life from military deployments may have some parallels with other occupational groups that deploy overseas from their home countries, such some business

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Centre for Military and Veteran’s Health offer Master of Public Health (Defence)

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world. 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.

To find out more about CMVH Defence health courses contact the Professional Development Officer on (07) 3346 4860, cmvh@uq.edu. au or visit www.uq.edu.au/cmvh

The Masters of Public Health (Defence) 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. With exit options, distance education and part-time studies, the Masters of Public Health (Defence) Program can adapt to students’ heavy workloads and pending deployment. The CMVH’s range of specialised short courses is 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, global environmental health, and nuclear, biological and chemical defence. Short courses include Health Aspects of Disaster, Communicable Disease Control, Introduction to Military Medicine and Occupational and 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. CMVH courses are internationally-renowned and accredited and can increase the employability of health workers around the ADF Health | Vol 10 No. 1 | 2009

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personnel, college students and missionaries. Research with US corporations30 found that nearly a half of companies reported problems with attrition among returnees, with up to three-quarters of personnel anticipating that they would not be working for the same company one year later and one-quarter actually leaving31. Up to 15% felt uncomfortable due to their deployment more than a year after returning26. Research with repatriating business personnel and other groups,25 demonstrated that during deployments there are two different psychological adjustments required. Firstly, there is acculturation to the host country, and secondly, re-acculturation to the homeland. However, while threequarters of corporations studied had orientation programs for employees heading overseas, only one-quarter having repatriation programs for returnees.

Research with Australian Reservists An initial review of responses from Australian Army reservists who deployed to Timor L’Este in 2002 and to the Solomon Islands indicate they experienced reactions to reintegration including leaving the ‘military milieu’ and returning to their home unit; issues related to separation from family and reunion with friends and community; changes in self, affective responses, and coping strategies; and issues related to underemployment, work motivation, and career uncertainty33. Challenges for Australian Army reservists around post deployment re-entry and reintegration include individual return, readjustment, personal change, reacculturation and successful reintegration to civilian employment23. Australian reservist doctors27 report that deployment could lead to “guilt and a feeling of desertion” and that “you come back exhausted mentally and physically”. Such feelings can be related to grief surrounding loss of role, status, and relationships acquired on deployment. Over half of reservists deployed report some reintegration problems relating to their personal and work life and just under half report reintegration problems in their family life, up to two years after repatriation. However, the deployment experience for Australian Army reservists is generally regarded positively with low rates of actual mental health issues. At three years’ post deployment, rates of retention in the service were higher for reservists (79%) than for their permanent counterparts (49%) on the same deployment. Additionally, 15% of reservists have transitioned to the regulars following their deployment.

What can be done? Most reservists settle in well and resume their civilian roles in a positive fashion. Military service, especially when it has involved physical challenges, learning new skills and the application of years of training, leads to increased confidence and self-belief. This is generally a great asset to any employee and leads to improved capacity for responsibility and contribution in the workplace, though many reservists do report loss of motivation in the early stages of return to their civilian roles21. In recognition of the unique experiences of deployment on reservists, some militaries are responding with re-integration programs tailored to reservists. Funding for specialist reintegration programs in the U.S. and their development

has increased significantly in the past few years21 with the introduction of the US National Guard and Reserve Mental Health Access Act (2008). Similarly, the UK has established the Reserve Mobilisation Training Centre (RTMC) at Chilwell, to enact a standardised approach to preparation for deployment and also redeployment (including re-entry) for all reservists (TA) and civilian personnel; and ‘Reserve Mental Health Program’, which aims to improve recognition of problems in primary care for reservists. These programs include comprehensive and supported strategies to ensure optimal health; both physical and mental, to ease the transition to usual life. The process of unwinding from the demands of any deployment, including decompression activities, is crucial along with a host of other well placed strategies to ensure each returnee’s health, well being, and post deployment reintegration.

Conclusion The re-entry and reintegration experience of reservists is not well understood and their adjustment will usually longer than their contracted period of full time service. It is likely that given the current operational tempo, reservists deployed once, may well be called upon to serve on deployment again. This is certainly the experience of many specialist reservists such as medical personnel who may have deployed on multiple occasions. The adjustment from one deployment may impact on subsequent deployments. The increase in representation by reservists on ADF deployments in Australia and overseas is relatively recent, and gives rise to the need to develop a range of modified, adapted or new approaches for reservists to ensure their successful re-entry and reintegration following a deployment or ‘deployment-like’ experience, especially as reservists may be called on to deploy repeatedly. However, at this stage there is no clear picture of the impact of deployments and the health needs of reservists who deploy, for Australian reservists. Research in the field is in its infancy and as demonstrated in this paper, the research in inconclusive. While reservists may face the same deployment challenges as permanent forces, their reintegration environment may be substantially different and more complex. Some research suggests greater problems for reservist due to these challenges; however early Australian research suggests the opposite. It is perhaps, more that reservists are ‘out of sight and out of mind’ that leads to a lack of understanding. The importance of successful re-entry and reintegration for such ‘high net worth’ military personnel, whose skills may well be in short supply, such as medical specialists, and who may be asked to serve repeatedly, is readily apparent. It is the responsibility of the ADF who increasingly rely on reservists, to understand and cater for the unique experiences of integration and re-integration of reservists, as much as they do for permanent forces.

References 1.

Weitz R. The reserve policies of nations: a comparative analysis. Strategic Studies Institute 2007 Available from: URL: http://www. StrategicStudiesInstitute.army.mil/

2.

Blum LS. Dual mission commitments. The Officer 2008; 84: 4.

3.

Australian National Audit Office (ANAO). Report No. 31: Army reserve forces 2008 Available from: URL: http://www.anao.gov.au/

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4.

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Thie HJ, Conley, RE. Past and future: insights for reserve component use. RAND National Security Research Division 2004 Available from: URL: http://www.rand.org/pubs/ Power MN. Australian Defence Force reserves: attitude survey report 2005 2004. Directorate of Strategic Personnel Planning and Research Available from: URL: http:// intranet.defence.gov.au/dmoweb/sites

personnel who deployed to the 2003 Iraq war: a cohort study. Lancet 2006; 367: 1731-41. 13. Wynd C, Ryan-Wenger, NA. The health and physical readiness of army reservists: a current review of the literature and significant research questions Military Medicine 1998; 163: 283-7

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Kearney GC, Marshall R, Goyne, A, editors. Military stress and performance: The Australian Defence Force experience. Melbourne: Melbourne University Press 2003.

14. Schwartz DA, Doebbeling BN, Merchant JA, Barret DH et al. Self-reported illness and health status among Gulf War veterans: a population-based study Journal of American Medical Association 1997; 277: 238-245.

7.

Haas KL. Stress and mental health support to Australian defence service personnel on deployment: a pilot study. ADF Health 2003; 4: 19-22

15. Turner M, Kiernan, MD, McKechanie, AG et al. Acute military psychiatric casualties from the war in Iraq. Br J Psychiatry. 2005; 186: 476-479.

8.

Hoge CW, Auchterlonie JL, Milliken CS. Mental health after deployment to Iraq or Afghanistan: a reply. Journal of the American Medical Association 2006; 296: 516

9.

Murphy PJ. The stress of deployment. In: Kearney GC, Marshall R, Goyne, A, editors. Military stress and performance: The Australian Defence Force experience. Melbourne: Melbourne University Press 2003. p. 3-18.

16. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq War. Journal of the American Medical Association 2006; 298: 2141-48.

10. Yerkes SA, Holloway HC. War and homecomings: the stressors of war and of returning from war. In: Ursano RJ, Norwood AE, editors. Emotional aftermath of the Persian Gulf War: veterans, families, communities, and nations. Washington, DC: American Psychiatric Press 1996. p. 25-42. 11. Browne T, Hull L, Horn O, Jones M, Murphy D, Fear N T, Greenberg N, French C, Rona R J, Wessely S, Hotopf M. Explanations for the increase in mental health problems in UK reserve forces who have served in Iraq. Br J Psychiatry 2007; 190: 484-489. 12. Hotopf M, Hull L, Fear N T, Browne T, Horn O, Iversen A, Jones M, Murphy D, Bland D, Earnshaw M, Greenberg N, Hughes J H, Tate A R, Dandeker C, Rona R, Wessely S. The health of UK military

17. Blais, AR. The development and validation of the Army post-deployment reintegration scale. Military Psychology 2009; 21: 365-388. 18. Iversen AC, Greenberg N. Mental health of regular and reserve military veterans Advances in Psychiatric Treatment 2009; 15: 100-9. 19. Vaitkus, M. An evaluation of unit replacement on unit cohesion and individual morale in the U.S. Army all-volunteer force. Military Psychology 1990; 2: 221-39. 20. Grossman, D. On killing: the psychological cost of learning to kill in war and society. New York: Little Brown & Company; 1995. 21. Minnesota National Guard Minnesota National Guard 2007 annual report. 2008 Available from: URL: http://www. minnesotanationalguard.org/aboutus/ 22. U.S. Commission on the National Guard and Reserves, Report of the Commission on the National Guard and Reserves 2008 Available from:

URL: http://www.csis.org/commissionnational-guard-and-reserves-report. 23. Stendt DM. A nurse’s experience in Iraq. ADF Health 2006; 7: 87-91. 24. Gullahorn JT, Gullahorn JE. 1963 extension of the u-curve hypothesis. Journal of Social Issues 1963; 19: 33-47. 25. Sussman NM. Repatriation transitions: psychological preparedness, cultural identity, and attributions among American managers. International Journal of Intercultural Relations 2001; 25: 109-23. 26. Black JS, Gregerson HB, Mendenhall ME. Toward a theoretical framework of repatriation adjustment. Journal of International Business Studies 1992; 23: 73760. 27. McGilvray A. Double duty Australian doctor 2008 Available from: URL: http://www. australiandoctor.com.au/articles.asp? 28. Selby S. Disenfranchised grievers: The GP’s role in management. Australian Family Physician 2007; 36: 768-70. 29. Jordon P Re-entry: Making the transition from missions to life at home. Seattle, WA: Youth With A Mission (YWAM); 1992. 30. Storti C. The art of coming home. Yarmouth ME: Intercultural Press, Inc; 2003. 31. Black JS, Gregersen HB, Mendenhall ME 1992 Toward a theoretical framework of repatriation adjustment Journal of International Business Studies 1992; 23: 73760. 32. Faber AJ, Willerton E, Clymer SR, MacDernid SM, Weiss HM. Ambiguous absence, ambiguous presence: A qualitative study of military reserve families in wartime. Journal of Family Psychology 2008; 22: 222-30. 33. Orme LTCOL G. Post deployment reintegration of Australian Army Reservists. In: Proceedings of the 11th European Conference on Traumatic Stress; 2009 Jun 15-19; Oslo, Norway.

Casualty retrieval exercise from an engine space at sea

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TRAINING

Definitive Surgical Trauma Care Course (DSTC)

Honours and Awards ADF Health notes with acclamation the following award in the Australia Day Honours 2009: CMDR Malcolm Stening (Ret’d): MEDAL (OAM) IN THE GENERAL DIVISION OF THE ORDER OF AUSTRALIA. For service to medicine as a gynaecological surgeon, and to the community through the recording of naval history.

DSTC Australasia in association with IATSIC (International Association for Trauma Surgery and Intensive Care) is pleased to announce the courses for 2010. The DSTC course is a valuable and exciting opportunity to focus on: • • • •

Surgical decision-making in complex scenarios Operative technique in critically ill trauma patients Hands on practical experience with experienced instructors (both national and international) Insight into difficult trauma situations with learned techniques of haemorrhage control and the ability to manage major thoracic, cardiac and abdominal injuries

The Definitive Perioperative Nurses Trauma Care Course (DPNTC) is held concurrently with many DSTC courses. It is aimed at registered nurses with experience in perioperative nursing and allows them to develop these skills in a similar setting. The Military Module is an optional third day for interested surgeons and Australian Defence Force Personnel. DSTC is recommended by The Royal Australasian College of Surgeons for all Consultant Surgeons and final year trainees. To obtain a registration form, please contact Sonia Gagliardi on (61 2) 9828 3928 or email: sonia.gagliardi@sswahs.nsw.gov.au

2010 COURSES: Melbourne: 8-9 February 2010 Sydney (Military Module): 27July 2010 Sydney: 28-29 July 2010 Auckland: 2-4 August 2010 Melbourne: 16-17 November 2010 ADF Health | Vol 10 No. 1 | 2009

ADF Health recognises the following officers who received awards in the June 09 Queen’s Birthday Honours: MAJGEN (Ret’d) John Pearn AM RFD: OFFICER (AO) IN THE GENERAL DIVISION OF THE ORDER OF AUSTRALIA. For service to medicine, particularly in the areas of paediatrics and medical ethics, to medical history, and to the community through injury prevention and first aid programs CAPT Mike O’Connor RANR: MEMBER (AM) IN THE GENERAL DIVISION OF THE ORDER OF AUSTRALIA. For service to medicine in the fields of obstetrics and gynaecology, particularly Indigenous maternal and perinatal health and through professional organisations. COL Susan Neuhaus: Conspicuous Service Cross (CSC) For outstanding achievement in the provision of medical support as the Commanding Officer of the 3rd Health Support Battalion.

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Anaesthesia

Field Anaesthesia Training for the Australian Defence Force George Merridew MBBS FRACGP FANZCA FFPMANZCA Group Captain RAAF Specialist Reserve

The history of Australian courses in field anaesthesia Group Captain George Merridew was Chair of the ADF’s craft group in Anaesthesia from 2000 to 2004. He has convened 10 field anaesthesia courses in Launceston, Tasmania, where he is in civilian practice. GPCAPT Merridew graduated from the University of Tasmania in 1972. After Permanent Air Force service from 1970 to 1979, he trained as an anaesthetist in Adelaide and qualified FFARACS (now FANZCA) in 1983. From 1983 to 1985 he continued his post-Fellowship experience in the UK, Hong Kong and the USA . He settled with his family in Launceston, where his clinical interests have included Pain Medicine, ICU, medical retrieval and field anaesthesia teaching. GPCAPT Merridew has deployed with the ADF in Irian Jaya, Rwanda, Bougainville, East Timor, Bali and Iraq.

Conventional anaesthetic training is not sufficient for field environments Anaesthesia for surgery must be effective and safe. The patient’s risk from surgery and anaesthesia must be less than from expectant management.

In 1985 and 1984 respectively anaesthetists Haydn Perndt and George Merridew attended the annual Anaesthesia in Developing Countries 5-day course in Oxford, UK. In 1999 an Australian equivalent was established, entitled: Remote Situations, Difficult Circumstances, Developing Country Anaesthesia (RSDCDCA) course. Dr Perndt (later SQNLDR, RAAFSR) ran the inaugural RSDCDCA at the Royal Hobart Hospital assisted by then-WGCDR Merridew and several civilian anaesthetists with substantial South Pacific Island experience. The 1999 course had 16 ‘students’; all were specialist anaesthetists. Eight ADF Reservists were either students or faculty. The RSDCDCA course has been held annually since, for civilian ‘students’. In 2000 a similar course but with a military bias for the ADF was commenced and referred to as the Military Anaesthesia (MILAN) course. Altogether 112 ADF members have attended an Australian field anaesthesia course; 96 of those attending a MILAN course. Eighty four of those 112 still serve in the ADF. The participants include: • • • • • •

15 anaesthetic registrars in training 4 intensive care physicians (FRACP FJFIJM) 4 General Duties Medical Officers 5 Nursing Officers 2 Medical Assistants 5 Allied Forces personnel: 4 USN and 1 Canadian Armed Forces • 12 other ADF anaesthetists, now-retired

Some deployments conform with the conditions in metropolitan Australian hospitals, where preoperative patients are healthy and well-assessed, the surgery is elective and there are reliable anaesthesia apparatus, drugs, monitoring devices, air conditioning, electricity, suction, compressed gases and skilled assistance.

Twelve anaesthetic consultants (mostly members of the ADF) have attended as faculty, assisted by 9 civilian registrars with drawover experience.

Other deployments involve unstable, poorly investigated nonEnglish-speaking patients having emergency surgery to save life or limb. The ADF anaesthetist may have limited choices: general anaesthesia with parenteral ketamine or a drawover inhalational agent, positive pressure ventilation rendered by a self-inflating bag’s ambient air ±added oxygen; and no electronic monitoring. Operating room temperatures can range from near freezing to over 40 degrees Celsius.

Since 1991, the author has undertaken extensive bench testing of field anaesthesia apparatus in the Launceston General Hospital (LGH). That testing has included ADF, UK and US military and civilian anaesthesia vaporisers, examining their performance in the range of ambient temperatures and gas flows conceivable for surgery in the field. Also examined were oxygen delivery to the patient and the apparatus’ resistance to gas flow especially in the drawover mode of use.

Western civilian anaesthetic training occurs in hospitals which adhere to national regulations for operating rooms and other hospital environments. Most Third World hospitals and field situations are far removed from such standards.

Military anaesthetists are more versatile if trained in the drawover technique, especially relevant to comparatively austere ADF surgical facilities such as in Bougainville, East Timor and Banda Aceh.

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What is the ‘drawover anaesthesia’ technique? The drawover technique delivers controlled concentrations of oxygen and anaesthetic vapour. It involves: A vaporiser of low resistance to gas passing through it (the carrier gas), such as the Oxford Miniature Vaporiser in the ADF’s Field Anaesthesia Machine The carrier gas is ambient air (± supplementary O2). Carrier gas flow is generated by the patient’s inspiratory effort, or by a self-inflating (Laerdal or Ambu) bag filling from the circuit between the vaporiser and patient. A non-rebreathing circuit, typically using a Laerdal valve at the patient end. None of the patient’s expired gas enters the drawover circuit hose between the vaporiser and patient (unlike the ubiquitous ‘circle’ circuit of Western hospitals) so it does not dilute vapour or oxygen coming from the vaporiser to the patient. Supplementary oxygen is fed into a ‘reservoir tube’ of 400500 mls volume open to atmosphere and attached to the vaporiser’s upstream side. Oxygen enters at the reservoirvaporiser junction; flows of 0, 1 and 4 litres/minute give inspired oxygen concentration (FiO2) of 21%, 30-40% and 60-80% respectively.

Designing the Australian field anaesthesia courses, civilian or military Anaesthetists won’t use inhalational techniques unfamiliar to them, a key fact addressed by the courses. RSDCDCA and MILAN courses emphasise drawover anaesthesia for three reasons: 1. It is the safest inhalational technique for surgery in settings with unreliable supply of oxygen and/or electricity. 2. Few Australian anaesthetists have used drawover apparatus. 3. In the field or anywhere else, the drawover circuit (± its vaporiser) reliably supports oxygenation and ventilation, whether for inhalational or totally intravenous anaesthesia, for problematic local anaesthetic blocks and for respiratory resuscitation. The courses have lectures on the performance of drawover apparatus. Each ‘student’ uses the drawover technique on consenting patients, supervised by drawover-competent faculty. Students are observed by their colleagues, in groups of three or four per operating room. Standard patient monitoring is used, and highlights the inspired oxygen and anaesthetic vapour concentrations. Isoflurane is the main agent used, with lesser emphasis on sevoflurane. Diethyl ether is not used. Few patients decline the invitation to participate and those who do refuse use the grim words: “I was told I would be having a spinal”. The host hospital surgeon or anaesthetist of the case can veto the patient’s participation, a rarity in over 500 cases. The host State medical board registers course members for the period of the course. Each course has been supported not only by the hospital’s clinicians and administrators but also the respective councils of the Australian Society of Anaesthetists and Australian and New Zealand College of Anaesthetists

(ANZCA). “Students’ and faculty gain credits in ANZCA’s Continuing Professional Development process. The original course design has remained substantially unchanged. It includes: • Drawover technique in theory and practice • Comparing drawover and other inhalational anaesthesia systems • Ketamine anaesthesia • Local infiltration, peripheral nerve blocks and spinal anaesthesia • Pain relief after surgery or other trauma • Ventilators, suction systems, monitors and oxygen concentrators • Sterilisation of instruments and other equipment • Obstetric and paediatric anaesthesia • The difficult airway • Intensive care • Medical retrieval by air and land • Cultural aspects of medical care • Ethical issues: the allocation of limited resources • Mass casualty management • Personal hazards to the deployed anaesthetist and his/ her family • Motivations for deployment • Personal accounts by deployed anaesthetists • Psychological adaptation to a new environment • International civilian aid

The ADF’s field anaesthesia course The basically civilian RSDCDCA course in 1999 was heavily over-subscribed by civilians; it continues to be so. If even four places on an annual such course of 16 ‘students’ were quarantined for the ADF it would take 20 years for the 80 current ADF anaesthetists each to attend. Consequently, in 2000, ADF courses were begun, in Launceston. Similar courses have been conducted at LGH almost annually until 2007, with the support of the ADF’s Joint Health Commander. The duration of ADF courses has been three days. Its military bias includes: • The ADF’s ULCO field anaesthesia machine • FAST and other ultrasound techniques • Shipboard resuscitation, anaesthesia and intensive care on HMAS MANOORA and HMAS KANIMBLA • Organisation of ADF health facilities, and routines on deployment • Contrasting patterns of injury in various deployments such as Rwanda, East Timor and the Middle East • Anaesthesia, intensive care and aeromedical evacuation in the ADF • Personal accounts of deploying • Emotional reactions to deployment, during and afterwards

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• Implications for families of deployed anaesthetists The ADF course assumes ‘students’ have a comprehensive knowledge of anaesthesia and targets ADF Reservist anaesthetists either holding or preparing for the FANZCA. Many are ex-Regular Forces medical officers with much relevant military experience. By late 2009 only about 12 ADF anaesthetists have yet to participate. Also targeted are: • ADF Reserve intensive care physicians holding a medical specialist qualification (FRACP) • ADF Reserve and Regular Nursing Officers and Medical Assistants who train ADF theatre technicians • Senior ADF Medical Officers, especially hospital commanding officers • Health staff from allied forces, especially US Navy Medical Logisticians on exchange posting to the HMAS MANOORA-KANIMBLA project.

Is servicing and resupply reliable for any deployed ADF surgical facility? No. Should the ADF field anaesthesia course include extensive teaching about damage-control surgery and the aggressive management of severe trauma-related coagulopathy? No. Detailed teaching on this should be confined to external civilian courses. Should the ADF course include extensive teaching of peripheral infusion local anaesthesia invaluable in awake ICU or AME trauma patients? No. This should again be restricted to external civilian courses..

Conclusion The ADF’s field anaesthesia training should continue in its present design, to evolve as circumstances require.

Acknowledgements • The courses’ enthusiastic faculty members, ADF and civilian

Potential Changes to the ADF courses Should we hold the course in an ADF hospital? Although somewhat attractive, such a change would be impractical because ADF hospitals have too few operating rooms to provide the key clinical experience in drawover anaesthesia. Can clinical drawover use be replicated by simulation training? Simulation would eliminate the ‘hands-on’ element central to training with inhalational apparatus. Human patients are likely to remain a feature of the ADF course. Should drawover training be abandoned entirely? Recent operational health deployments have involved well-resourced multinational surgical facilities treating mainly severe multiple trauma from high-energy bullets, roadside bomb blasts and burns. Drawover anaesthesia has not been used by ADF personnel working in such facilities. Will the ADF ever again deploy a low level surgical facility like the Combined Medical Element (CME) of Bougainville, an RAAF Fly Away Surgical Team or an RAAMC Parachute Surgical Team? Yes.

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• The ADF course staff officers, for substantial administrative help • The staff and patients of the Launceston General Hospital • The Medical Council of Tasmania

References 1.

De Sousa H. Equipment for anesthesia in difficult and isolated environments. Ch 29 in: Anesthesia equipment: Principles and applications. Ehrenwerth J, Eisenkraft JB, editors. Mosby -Year Book St Louis: Mosby, 1993.

2.

Dobson MB. Anaesthesia for difficult locations, developing countries and military conflicts. Ch 118 in: International Practice of Anaesthesia. Prys-Roberts C, Brown BR, editors, Oxford: Butterworth Heinemann, 1996.

3.

Houghton IT. The Triservice Apparatus. Anaesthesia 1981; 36:10941108,

4.

Merridew CG. Anaesthesia by Acronym... EMO, OMV, PAC Australasian Anaesthesia 2000. Keneally J, Jones M., editors, ANZ College of Anaesthetists, Melbourne. ISSN 1032-2515

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Training

Medical Officer Underwater Medicine Course – 16 to 27 Nov 2009 LEUT Peter Smith RAN

LEUT Peter Smith is a medical officer at the Submarine and Underwater Medicine Unit (SUMU). He is currently studying for his postgraduate qualification in diving and hyperbaric medicine, with a special interest in oxygen diving. He is also a very part-time anaesthetic registrar, and at the time of writing is deployed to the MEAO in HMAS TOOWOOMBA in support of OP SLIPPER and anti-piracy operations. In a previous life, he was a Psychologist in the Navy Reserve. Correspondence: LEUT P Smith MB BS(Hons),MA Medical Officer,SUMU HMAS PENGUIN Middle Head Rd,Mosman 2088

T

he Medical Officer Underwater Medicine (MOUM) course is a two week residential course which provides the basic skills required to diagnose and manage specific medical problems associated with the marine hyperbaric environment. While the course focuses on diving medicine, it also includes medical aspects of submarine service, as well as some discussion of hyperbaric treatment applications in a broader environment. The course also teaches assessment of fitness for military diving, as well as broader civilian requirements for diving. This includes statutory requirements. The MOUM course is an integral part of the initial training continuum for full time RAN Medical Officers, and it is required for progression to Clinical Level 2 (CL2). It is also a recommended clinical course for the other Services and there is strong demand for positions on it. The MOUM course is an accredited component of the coursework element of the Diploma in Diving and Hyperbaric Medicine. Civilian medical practitioners and military doctors from other nations may also attend. However, there is often a waiting list. The RAN Underwater Medicine Medical Officer’s

Course intersects with the Prince of Wales Hospital (POWH) Hyperbaric Medicine course: the Navy course focuses on diving medicine and fitness assessment, together with other applications of hyperbaric oxygen therapy. The complementary POWH course has a significant emphasis on hyperbaric medicine, while also covering diving medical assessments, diving physiology and medical management of diving-related problems. The course itself is conducted by the RAN Submarine Underwater Medicine Unit (SUMU), which is located at HMAS Penguin

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on Sydney Harbour’s Middle Head Peninsula. While most of the course is conducted on site, it includes a half-day tour of the POWH Hyperbaric Unit and an afternoon teaching session there. The course includes lectures, small group activities, clinical scenarios and practical components. The practical activities include familiarisation with diving equipment and the opportunity for supervised dives with SCUBA air and re-breather sets, as well as a dry dive in the SUMU recompression chamber. The course is informally assessed throughout and then by a final written examination. The teaching faculty is highly regarded and includes numerous visiting authorities on diving medicine, various subject matter experts and often international speakers. The syllabus aims to cover most aspects of diving medicine and begins with an introduction to the relevant laws of physics. Diving physiology, particularly its cardiovascular and respiratory aspects, is an important part of the course. Participants are introduced to the theory and operation of diving equipment, different types of diving, and the demographic aspect of diver populations. The pathophysiology of diving and a discussion of specific diving illnesses take up much of the course. Specific diving problems covered include decompression illness (DCS), cerebral arterial gas embolism (CAGE), barotraumas (in all its manifestations) and gas toxicities (oxygen, carbon monoxide, carbon dioxide, nitrogen narcosis). The curriculum also includes marinerelated medical problems: near-drowning, salt water aspiration syndrome, hypothermia, and marine envenomation. Aetiology, risk factors, diagnosis, treatment and outcomes are discussed for each subject area. Submarine medicine is discussed, including fitness for submarine service, the submarine environment and health effects .The physiological consequences of sudden changes in pressure during submarine operations and in escape, methods of submarine escape and rescue, pressurised escape training and treatment of submarine casualties are important parts of that module. Other areas covered include causes of death in diving, practical workshops covering diving medical examinations, practical simulated activities including retrieval of casualties and full management of recompression treatment, occupational diving. There is some discussion of tactical diving, including mixed-gas and oxygen diving. ADF Health | Vol 10 No. 1 | 2009

Comparisons of different treatment regimes to manage diving casualties in both well resourced and isolated environments are made. Controversial topics such as a shared-risk approach to diving examination, as well as different approaches to asthma, diabetes and other diving contraindications are also discussed. Attendees wishing to participate in the practical diving activities, including the chamber dive, must have a ‘fitness to dive’ certificate prior to attending the course. For military members, this requires examination and certification from a qualified MOUM. Civilian attendees need an equivalent civilian fit-to-dive certificate from a South Pacific Underwater Medicine Society (SPUMS)-registered diving doctor. Failure to obtain a ‘fit to dive’ certification prior to the course does not preclude an applicant from completing the course, but will prevent that person from gaining the practical experience of the dives. The MOUMC attracts a large number of interested applicants from various clinical backgrounds with only 25 places available on offer. Successful completion of the course means that participants can conduct diving and submarine medicals, as well as diagnose and initially manage diving and submarine related illnesses and injury. They may also apply for recognition by SPUMS and the Royal Australian College of General Practitioners. The

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Training

Medical Officer Underwater Medicine Course (continued) course is one of three Australian courses recognised by SPUMS that satisfies the academic component of a Diploma of Diving and Hyperbaric Medicine. For further information visit the SPUMS website: (www.spums.org.au). The course cost for civilians (Defence contractors and external medical officers) is $705 per student (excluding meals and accommodation) or $2,008 (including meals and accommodation). If you are interested, or require further information please contact the course manager Mr. Rajeev Karekar via email (rajeev.karekar@defence.gov.au) or OIC SUMU LCDR Sarah Lockley (sarah. lockley@defence.gov.au)


Training

The ADF Aviation Medical Officers (AVMO) Course SQNLDR Adam Storey Chief Instructor

SQNLDR Adam Storey graduated MB BS (Hons) from the University of Queensland in 2000 and completed his residency years in Brisbane before joining the RAAF. He has been based at RAAF Tindal and Amberley and is currently the Chief Instructor in AVMED at RAAF Edinburgh. He holds a Bachelor of Science and a Diploma in Aviation Medicine.

T

he RAAF Institute of Aviation Medicine (AVMED) at RAAF Base Edinburgh has a primary responsibility to provide training to a range of ADF health specialist officers with the necessary knowledge and skills to assess and manage the health of ADF aircrew and aviation personnel. In addition, health specialists can also provide informed advice to command on aviation medicine topics and thus provide integrated aviation medical support to ADF flying operations. Aviation medical support is thus a vital ADF capability forming a cornerstone of maintaining a healthy force of aircrew.

same experts for specialist opinion in support of decisions for fitness to fly in complex clinical cases for ADF aircrew. Practical evolutions form an integral part of the AVMO course and include hypobaric chamber and hypoxia awareness training, experience with night vision goggles (NVG) and the NVG terrain board and spatial disorientation demonstrations in AVMED’s integrated physiological trainer. This course also includes a remote sea survival and rescue training exercise near Adelaide, where students are dropped into the sea with standard aircraft survival aids to facilitate some familiarity with survival at sea and available survival aids. At its conclusion the course participants and selected ADF aircrew are winched from the sea utilising Navy or Army helicopters. The final practical exposure is that students are afforded actual high performance flight experience with specific PC-9 sorties, to facilitate individual experience of the stressors of flight within the aerospace environment and to demonstrate illusions of flight and the effects of spatial disorientation and motion sickness in the air. To honour the legacy of the late Lieutenant George Merz1, who was the first ADF Aviation Medical Officer, the Lt. George P Merz Prize is awarded jointly by AVMED and the Australasian Society for Aerospace Medicine (ASAM) to the dux of each AVMO Course. Merz was a young Melbourne doctor who

Courses offered by AVMED to ADF health specialists include the biannual Aviation Nursing Officer (AVNO) course, the normally biennial Aviation Dental Officers (AVDO) course and the flagship course for Aviation Medical Officers (AVMO). The AVMO course is of five weeks duration and is open to all ADF medical officers in both the full-time and reserve forces, including Specialist Reservist members. This course aims to provide intensive training in human physiology, psychology and human factors in aviation. This course also includes core elements covering deployed aviation medicine support to operations in the three Services as well as aircraft accident response and investigation. In addition to graduating students qualified as ADF AVMOs, this course also qualifies graduates as certified Designated Aviation Medical Examiners (DAME) with the Civil Aviation Safety Authority (CASA). This enables them to provide comprehensive medical care to civilian aircrew. Many components on the AVMO course are taught by RAAF Specialist Reserve consultants, many of whom have previously attended the same course as students. AVMED often uses these ADF Health | Vol 10 No. 1 | 2009

Fig 1: FLTLT Merz in a box kite

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enlisted with the Australian Flying Corps (AFC) during World War One and participated in the first flying course at Central Flying School at Point Cook. Despite being neither the first to fly solo, nor the first to gain his ‘wings’, he did graduate as Dux of his course. Subsequently Merz was deployed to the Middle East in 1915 and during his deployment as part of the Mesopotamian Half-Flight, he flew reconnaissance missions from Asmara in support of the allied offensive on Baghdad. However later that year Merz was killed whilst flying a mission to Basra. Merz left a great legacy to ADF Aviation Medicine: he was not only the first ADF AVMO but also the first AFC airman to die in wartime service. The importance of aviation medical support to aerospace operations has meant an increasing demand for trained AVMOs in support of ADF deployments. These represent a significant component of current ADF operations abroad. In order to enhance provision of a competent aviation medical support capability to ADF, AVMED hosted the inaugural AVMO Refresher Course in August 2009. The course is a one week intensive course. It is aimed at practicing AVMO’s who wish to refresh their theoretical knowledge in aviation medicine and update their experience with current and future trends in aircraft, life support technology and clinical management of ADF aircrew.

Fig 2: Survival at sea exercise

Fig 3: PC-9 sortie

Following the success of that course, AVMED plans to introduce a similar one week familiarisation course in aviation medicine for ADF Specialist Reserve members in 2010 or 2011. Whilst this course will not graduate students as AVMOs, it is aimed at ADF Specialist Reservists who are keen to gain an understanding of aviation medicine in support to ADF aerospace operations.

References 1.

Smart, TL. Remembering Lieutenant Merz: Australia’s military aviation medical officer pioneer. Journal of the Australasian Society of Aerospace Medicine 2005; 2 (1): 9-15.

Fig 4: AVMED chamber exercise

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Training

Deployed Surgeons Obstetric and Gynaecologic Skills (DSOGS) Course CAPT Mike O’Connor AM RANR Chairman, Chapter of Military Obstetrics and Gynaecology Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Introduction The ADF Consultative Group in Obstetrics and Gynaecology (CGOG) and the Chapter of Military Obstetrics and Gynaecology of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (CMOG) have been concerned for at least 10 years about the lack of training and experience in obstetrics and gynaecology for deployed specialist general and orthopaedic surgeons. Such skills may be required for two main patient groups: 1. Female ADF servicewomen on deployment-usually about 10%1 of the total deployed force. In East Timor health care also included responsibility for women from NGO’s as well as female United Nations staff. For these women the standard of care may otherwise fall short of that expected in Australia. 2. Local women from the Area of Operations (AO) presenting with a range of obstetric and gynaecological problems. Many of these are severe and life threatening obstetric complications such as uterine rupture, eclampsia or massive post partum haemorrhage. The CGOG & the CMOG recognise that the primary purpose of the deployed surgical unit is surgical military support. However the overwhelming majority of recent ADF deployments have had a humanitarian assistance (HA) component and indeed it would seem that humanitarian aid by the Joint Health Command (JHC) is becoming an instrument of Australian foreign policy2. The culmination of such HA support was seen in the Tsunami Assist operation after the Boxing Day, 2004 tsunami in Sumatra. The major purpose for JHC staff deployment on that occasion was HA. Approximately 3,700 medical procedures were performed at the ANZAC Field Hospital including 275 surgical operations and 19 obstetric confinements3. It was described as the ‘largest humanitarian assistance mission that the ADF has ever undertaken’4. A subsequent deployment, Operation Pakistan Assist, which followed a devastating earthquake near Muzaffarabad on the

Pakistan side of the Kashmir Line of Control,was also primarily focussed on humanitarian assistance: 9500 medical treatments and over 4000 immunisations were given and there were 5 obstetric confinements5.

An ADF Skills Course on Emergency Obstetrics (DSOGS) Commencing in 2005 the CGOG and CMOG have conducted four day long courses in emergency obstetrics and gynaecology for ADF surgeons and support health personnel. These have been termed Deployed Surgeons Obstetrics and Gynaecology Skills (DSOGS) courses. The courses rely on participants absorbing an extensive package of prior reading which is now provided electronically several weeks before the planned date. During the course a team of anaesthetists, gynaecologists, and ultrasonologists deliver practical modules including vaginal examinations, instrumental delivery, perineal repair, manual removal of the placenta, control of massive postpartum haemorrhage using balloon tamponade, films on caesarean section and caesarean hysterectomy. In addition an important component of the course is the live ultrasound scanning of women in advanced pregnancy. A key teaching aid is the lifelike pelvic models produced by Model-medTM which allow realistic experience of vaginal examinations, instrumental deliveries as well as manual removal of the placenta. The last two of these courses have been conducted at the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in Melbourne, the others being at the Medical Simulation Centre at Royal North Shore Hospital in Sydney and at 1 Health Service Battalion at Holsworthy in Sydney. Participants are provided with CD copies of the film on Caesarean Section for future reference. The typical program commences with brief lectures on the place of obstetrics on deployment and basic ultrasound physics .Groups of 4 or 5 candidates then rotate through skills stations at 45 minute intervals. There are skill stations on vaginal assessments in labour, instrumental delivery-especially vacuum extraction-pudendal block and perineal repair, manual removal of the placenta, balloon tamponade for management of massive postpartum haemorrhage, caesarean section and caesarean hysterectomy (video).

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Outcomes of DSOGS So far a total of 45 health personnel have completed the full day course and a further 20 have attended the short course held at 1HSB, Holsworthy as part of the Military Module of the Definitive Surgical Trauma Course in 2007. The table below indicates the spectrum of participants: Specialty

Number

General Surgery

10

Orthopaedic Surgery

13

Surgical subspecialty(other)

1

Anaesthesia

5

Intensive Care

2

Emergency Medicine

3

General Practice

8

Other disciplines

3

Fig 1. Sonosite training-vaginal probe.

Participants from all 3 Services have attended: 24 (53%) from Army, 13 from Navy (28%) and 8 (17%) from Airforce. The response of participants has been very positive especially in relation to the experience afforded in practical skills in vaginal examination, instrumental vaginal deliveries and other manoeuvres and the video teaching on caesarean section. No formal ADF recognition by Health Training Accreditation Group (HTAG) has yet occurred. This prevents full funding of participants for travel and accommodation. It also forces the organisers to rely on the goodwill of civilian tutors and organisations to provide services and facilities free of charge. The next DSOGS course will be in Adelaide on 10-11 April 2010.Live operating sessions on Caesarean Section are planned.

Fig 2. Vaginal examination exercise

Please email CAPT O’Connor if you are a medical officer and are interested in attending. celticdr@bigpond.net.au

Footnotes 1.

2.

3.

4. 5.

603 female ADF members were deployed in East Timor on Operation Warden (INTERFET) between October and December 1999.The total deployment was 6910 ADF personnel .i.e. 9% were female. Oxfam, Submission to Australian Defence White Paper consultation process (8 October 2008) http://www.oxfam. org.au/campaigns/submissions/Defence-White-Papersubmission-2008.pdf accessed 24 July 2009 Senator Robert Hill ,’More ADF Troops Return Home from Aceh’ Press Release (4 March 2005) http://www.minister. defence.gov.au/HillTpl.cfm?CurrentId=4696 accessed 24 July 2009 The Age (25 March 2005) Aussie tsunami aid troops head home’ Hon Robert Hill Hon Brendan Nelson, ‘Defence Minister Dr Brendan Nelson Welcomes Home ADF Medical Personnel From Pakistan’ Press Release (9 March 2006)

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Fig 3. Forceps delivery

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Training

Deployed Surgeons Obstetric and Gynaecologic Skills (DSOGS) Course (continued)

Fig 4. Delivery of the shoulders

Fig 5. Caesarean section

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History

Military Medicine in Elizabeth’s Time Con Scott Reed, OAM, M.Ph, M.B., B.S., F.R.A.C.P. Consultant Physician (emeritus) Sydney Hospital

Dr Reed is a retired consultant physician who was the longest serving member of the visiting staff at Sydney Hospital. A New Zealander by birth, he had service with the Hunter River Lancers as part of the Citizens Military Force (CMF) .The subject of this paper was also that for his Master’s thesis in Philosophy.

Introduction The year 1585 was pivotal for Queen Elizabeth I. Philip II of Spain had consolidated his hold on 15 of the 17 provinces of the Netherlands and was committed to consolidating Catholicism in Europe. The Spanish army under the Duke of Alva was in the Low Countries where it had been suppressing revolts from 1567. Elizabeth and her Privy Council decided to adopt defensive neutrality, despite William of Orange asking Protestant nations in 1583 for assistance. Elizabeth provided funds to defend the region, but this was insufficient to stem Spanish dominance, as only two provinces, Holland and Zeeland, had any viable military capability. In October 1584 the Privy Council authorised military aid to the Dutch, ratified by the Treaty of Nonsuch in August 1585. It committed England to a field force (under Robert Dudley, the Earl of Leicester) of 5,000 men, 1,000 cavalry and an additional 1,150 men for garrison duty. Further financial aid was also promised.

Medical Support for Armies From the time of Henry VIII, it was understood that there would be a medical component to any military force. The appropriate medical establishment was considered to be one ‘medical practitioner’ to each band of 100 soldiers. Losses from non-combat causes in campaigns in France from 1589 to 1591 totalled 11,000 English dead, of whom only 1,100 died in combat. Mortality from unsanitary conditions, leading to typhoid and gastroenteritis, were common. Typhus or ‘camp

fever’ was also an ever present threat due to the presence of the carrier, the body louse, always a problem among dirty soldiers. Troops also suffered from exposure and malnutrition. Medical manpower for military campaigns was drawn from several sources. From the charter granted to the BarberSurgeons Company, which was incorporated in 1541 by Henry VIII, it is clear that it was expected to supply manpower on demand. However there were not sufficient members to meet the need. For instance, in 1577 there were only 90 persons on the roll. The Barbers’ arts and skills had developed in response to the dissolution of the monasteries and the consequent loss of their role as hospitals. Barbers had previously acted as assistants to the monks. To the troops, unlicensed practitioners would have been quite acceptable as in their home life they were the accepted healers. Many healers were skilled in advising, tending wounds, suturing, dressing burns and setting bones. The status of the army surgeon was reflected in his pay, which was same as that of a drummer. The English military surgeon Thomas Gale (15071587) pointed out to Elizabeth that such low pay would attract only the poorest standard of men as medical personnel. Unlicensed and unsuitable persons were particularly likely to serve late in the Flanders campaign. Officers were authorised to recruit their own surgeons. Any person who purported to give assistance to the ill and whose occupations involved healing the sick could be recruited. Apothecaries, a guild allied to surgeons and also trained by apprentiship, were also enlisted. By the end of the 16th century there were 100 apothecaries practising in London alone. In1518 Henry VIII had chartered the College of Physicians but it appears to have been mainly a ‘debating club’, contributing little to military medicine.

Health Support in Elizabeth’s Army The ideal ratio of Barber-Surgeons to soldiers was impossible to provide since Elizabeth’s forces numbered 32,000 by 1590. Most members of the medical force were unlicensed. Many women were involved in the healing processes in village medicine but their roll in the military was restricted to nursing duties. The Disciplinary Code of Leicester (i) states: therefore it is ordained that no man shall carrie into the fielde, or deteine with him in the place of his garrison, any woman whatsoever, other than such known to be his lawful wife, or such women to tend

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the sicke and to serue for launders, as shall be thought meete by the marshall, upon pain of whipping and banishment The most senior medical person in the army was William Clowes (c. 1540-1604) a Barber-Surgeon, who had been specifically requested by Elizabeth to attend Robert Earl of Leicester. He had been in military and naval service from the age of 18 and was very distinguished in military matters. As well as attending Leicester, he was ordered to attend to ‘the curing of the hurt and wounded soldiers’. Clowes, following his time in Flanders, wrote a most unflattering comment about the unlicensed practitioners in 1602: ‘beastlie abusers of physicke and chirurgerie, tinkers, tooth-drawers, pedlars, ostlers, carters, porters, horse-gelders and horse-leeches, idiots, apple-squires, broom men, bawds, witches, conjurers, sooth sayers and sow-gelders, rogues and ratcatchers, renegades and proctors of spittle-houses, with such rotten and stinking weed, which do in country, without order, honesty and skill daily abuse both physic and chirurgery, having no more perseverance, reason or knowledge in this art than hath a goose….and this is one principal cause that so many perish’2 This criticism may be harsh, for often unlicensed practitioners were the best that the recruiters could muster. The Army’s responsibility for public health was poorly understood. In 1544, Henry VIII issued an order: ‘prohibiting carrion, filth, or other unwholesome or infectious stinking thing to be near lodgings and the same to be buried’ .This demonstrates some awareness of the need to remove waste. The Earl of Leicester in his disciplinary code, (item 44) was more specific: ‘nor shall suffer the garbage to remain unburied, neither shall any man trouble or defile the waters adioyning, but in the lower part of the stream some good distance from the camp, under the payne of imprisonment’. Item 45 also forbad soldiers ‘to ease [himself] or defile the campe or toune or garrison, save in such places as is appointed for that purpose’. It can be inferred that hygiene was recognised by the military as desirable, probably more for reasons of camp comfort, rather than for health. However troops would hardly pay much heed to these when within their own cities and villages basic disposal of human waste and pure water supply was absent.

The Development of Military Medicine by William Clowes Clowes was an excellent observer and was prepared to use new methods in treatment. In 1588, he wrote ‘Prooved Practice for all Young Chirurgeons concerning Burnings with Gunpowder’. He warned that untrained persons should not stir gunpowder with their hands; no doubt he had seen burns occurring from premature ignition of gunpowder in the firing pans of guns and the resultant spill from too vigorous loading. Clowes tried to stop haemorrhage by applying ligatures (‘chokeband’) to the affected limb and the use of topical powders. He praised the dynamic French surgeon Paré for suggesting that the stump of an amputated limb should ADF Health | Vol 10 No. 1 | 2009

be sewn over in the shape of an X. Clowes did not specify suturing materials; but fine fibres from cow and horse tendons and horsetail hair were often used - and were strong suture materials. It is unclear whether needles were made of metal or bone. Another innovation was the avoidance of cauterising wounds: instead Clowes followed the lead of Paré and Thomas Gale in using local dressings. Both Paré and Gale advocated the use of onions in topical dressings of wounds. Onion and garlic contain allicin, an amino acid derived from cysteine. This has antibiotic properties against some common bacteria (including the common wound- infecting bacteria) which amount to about 2 percent of the potency of penicillin. There were glimmerings of recognition that infectious disease could be transmitted. Paré condemned flies as the carriers of ‘contagion’. The Frenchmen Philbert Guybet wrote ‘The Charitable Physician with the Charitable Apothecary’ in late Tudor times. Although not published in English until 1639, his ideas were probably developed during Elizabeth’s time. He wrote regarding the care of pipes for clysters (enemas), that should the patient have ‘pestiferous’ disease, the pipe should be washed and cleansed, warning that if this is not done the disease can be on the attending family within an hour. He recognized that unclean instruments could transmit disease. Clowes listed the composition of the ‘unguents and liniments’ for the young surgeon but did not deal with the problem of pain relief. There were early experiments in anaesthesia and pain on the Continent. The vapours from a mixture of opium poppy juice with mandragon derived from the herbs Mandrake and Henbane (hyoscyamus, scopolamine) made up a compound ‘spongia somnifera’. It could be delivered from a sponge saturated with the solution. This mixture was well known to Greek physicians and was probably derived from the Egyptians. Paracelsus knew about laudanum (tincture of opium) but he may not of have appreciated its analgesic properties. An early depiction of the technique of limb amputation was drawn by von Gersdorf in 1517. A woodcut of this illustration is held by the American College of Surgeons3. (see next page) The surgeon is using a cross-saw for a below knee amputation, there is a tie (an esmarche) below the knee, not above it if it was to act as a tourniquet. One of his assistants holds a bladder from a bull, ox or hog ready to be applied to the stump. The patient appears amazingly unrestrained and placid. Was he drunk or under the influence of an anaesthetic vapour? Perhaps he had been sedated with the ‘spongia somnifera’? Clowes did not describe any dental aspects of military surgery. However damage from any blunt trauma from a striking weapon would loosen, dislocate and remove teeth. Gunshot wounds to the face would open sinuses and probably lead to gross sepsis and death. If recovery did occur facial deformity might well have been grotesque. Dating from Tudor times, ‘tooth pullers’ attempted some degree of specialisation by designing a dental chair. Brunschwig devised a support for the chin for jaw fractures in 1497. Both Clowes and Paré suggested wiring the teeth together with gold wire to realign the jaw. Paré also advocated this method and also devised artificial ivory teeth on a gold base.

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manufactured false eyes. He attempted to treat fractured neck of the femur, recognised urinary straining as a symptom of prostatic hypertrophy and identified syphilis as a cause of arterial aneurysms. He published ‘Cinq Livres de chirurgie’ in 1582 and lectured at the Paris Faculty of Medicine which vigorously opposed his concepts of wound treatment. William Clowes knew of Paré’s work and acknowledged it by calling him a ‘master’. It is reasonable therefore to assume that the Barber-Surgeons knew that Paré had been advocating new methods of treatment. Why then were these developments not adopted? The teaching institutions were overseen and dictated to by the conservative College of Physicians and any advance or change had to be philosophically debated in the College before being accepted. Clowes drew on his experiences in the Flanders campaign, which ended in 1588, to write ‘A Brief and Necessary Treatise of Morbus Gallicus’. Later he changed the title to the more politically correct ‘Lues Venerea’. He was a firm advocate of mercury therapy for syphilis. He highlighted the problem of venereal disease in the military by devoting some of his treatise ‘A Proved Practice’ to the cure of syphilis and the use of mercury in therapy.

Reproduced with permission of the American College of Surgeons

English Military Medicine follows the Continental Lead

One of the greatest, but perhaps least known, events in military medicine occurred during the Siege of Metz in 1552. The siege was conducted by the Emperor Charles V against Francis, Duke of Guise and commander of the Metz garrison. Guise initiated basic hygiene measures by ensuring a clean water supply was placed under guard. Adequate food was rationed systematically; all carrion and body wastes were disposed of over the fortress wall and there was immediate isolation of the ill from the healthy. It was the duty of the ‘pioneers’ to clean the drains and the streets. The Barber-Surgeons of the nobles were required to treat anyone who required their services. There were no serious outbreaks of epidemic illness in the 65-day siege.

In the Elizabethan era, England was essentially a medical backwater. Continental medical superiority caused many physicians and Barber-Surgeons to attempt to raise medical standards in England by introducing advanced techniques into England; among these were Thomas Linacre, John Caius, John Hester, Peter Lowe, John Banister and, in particular Thomas Gale for his military input.

Guise and the Duke of Alva, from the imperial army, initiated a type of ‘Red Cross’ humanitarian arrangement to allow better treatment for prisoners. Guise fostered compassion to the enemy and organized river transport for enemy wounded at a time when it was the practice at the time to slaughter the wounded enemy.

Ambroise Paré (1510-1590) joined the French Army as a ‘self-taught’ field surgeon in 1537 soon after completing his apprenticeship. He wrote ‘Method of Treating Gunshot Wounds’ in 1545. (Not published in English until 1617). In Milan, he lacked oil with which to cauterize wounds and thus commenced possibly one of the earliest ‘controlled’ medical trials. He had a group of casualties whose wounds were treated with the conventional boiling oil for cautery and others who received dressings and an ointment of egg yolk, rose water and turpentine. The results in this second group of patients were dramatically better in terms of survival and patient comfort.

Early Management of Military Injuries

He advocated ligating major bleeding arteries and swift amputations above the wound as needed thus indicating a possible understanding of the physiology of the arterial system. He would not remove lead bullets, but did remove iron and other corrosive metals. Paré developed artificial limbs, and

What situations would confront the medical personnel in battle? Wounds due to slashing weapons and arrow wounds were expected but the compound fractures and gross tissue destruction would have been new challenges. Burns were a major and common trauma since fire was necessary close to a battle area, particularly in siege warfare. Pouring boiling oil from ramparts was common requiring cauldrons and a brazier nearby. Arrows were often tipped with burning cloth. Red-hot cannon balls were often used both on land and at sea. Leonard Digges wrote a pocket book for English army officers in 1571 outlining the qualities required for military medical service, but it was not until 1590 that his son Thomas had it published. His theories were well ahead of his time. Thomas Digges was the Muster-Master in the Netherlands from 1586 to 1594 and was later to become a distinguished astrologer.

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He wrote: Many times small wounds are made sometimes maymes and some times mortall. It is therefore fit that no surgeon in any bande be admitted till the surgeon-major of the regiment have examined with his skill. He ought to be provided of a good chest of salves, oyles and waters for killing the heat of shot, and all such instruments as are necessary for his art; without which and his testimonial from the surgeon-major of his sufficience, he ought not pass muster, or receive pay. He ought to be careful, honest and loving to the souldiers he hath in cure, and besides his ordinary pay of the prince, he is to have monthly somewhat out of every soulders pay, towards the charge of his chest of medicines, besides the rewards of such as are his abilities, to the end of the poore souldiers being cured gratis.

Military Hospitals Some English officers recognized the value of hospitals and recommended that churches and abbeys be converted to this purpose. However William Clowes, the senior English surgeon did not specifically comment on the need for a hospital near the battlefield. It was not until Elizabeth’s Irish campaign that provision was made for military hospitals in 1598. This was not implemented until the 1600’s. Clowes was subsequently appointed to St Bartholomew’s Hospital. St Bartholomew’s and St. Thomas’ Hospital in London were two of the few medieval hospitals to survive the dissolution of the Reformation. In Spain Queen Isabella had put the concept of a field hospital into practice in 1437 at the siege of Malaga, where the hospital was known as an ‘ambulancia’. Emperors Maximilian I and Charles V also arranged for wounded to be taken to the baggage train where they were treated in tents by medical personnel and nursed by women from the army train.

Late in Elizabeth’s campaign in the Low Countries a system of ‘guest houses’ for the sick and wounded was developed. House owners were required to look after the ill and to report on their condition to the muster-master and the treasurer-at-war. It is not clear who determined the rate of pay or if the soldier had to contribute for his keep.

Concluding Remarks The medical skills learnt during the Flanders campaign slowly influenced military medicine in England. Following Elizabeth’s Continental campaigns, new concepts of patient care there were recognised and adopted by the Barber Surgeons. English medicine finally began to emerge from a medical wilderness.

References 1.

Lawes and Ordinances set downe by Robert Earle of Leycester, the Queenes Maiesties Lieutenant and Captaine Generall of her Armie and Forces in the lowe Countries in Cruickshank, C.G. Elizabeth’s Army Oxford University Press, 1966 (2nd ed.). pp. 290-303.

2.

Celeste Chamberland, ‘Honor, Brotherhood, and the Corporate Ethos of London’s Barber-Surgeons’ Company, 1570–1640’ (2009) 64 Journal of the History of Medicine, pp.300-332.

3.

Hans Von Gersdorff Feldtbuch der Wundtarzney http://anestit. unipa.it/mirror/asa2/newsletters/1996/09_96/amputation.html accessed 2 September 2009.

4.

Cruickshank C.G. Elizabeth’s Army, Oxford: Oxford University Press, 1946.

5.

Fortescue J.W. A History of the British Army, Cambridge: Cambridge University Press, 1914.

6.

Young S (Editor). Annals of the Barber Surgeons of London from their Records and other Sources, London: Blades, East and Blades, 1843, reprinted 1890.

7.

Webster C (Editor). Health, Medicine and Mortality in the Sixteenth Century, Cambridge: Cambridge University Press, 1979:p.181

Operating in the PCRF

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History

Imhotep and the Origins of Ancient Egyptian Military Medicine AVM Bruce Short AM RFD FRACP (rtd)

Who was Imhotep? Bruce Short, a retired physician, sometime Surgeon General ADF and editor of ADF Health, is currently undertaking studies for a Master of Arts (History).

Imhotep, the first figure of a physician to stand clearly from the mists of antiquity. Sir William Osler1

Introduction Early in the Egyptian Old Kingdom, dated by 19th century historians as commencing in c. 2686 BCE1 lived perhaps one of the world’s most astonishing ancients, Imhotep. He was perhaps the first physician, engineer and architect in history known by name. Imhotep has been favourably compared with Leonardo da Vinci2. Although Jamieson B Hurry lists thirty variants in the English spelling of his name3, the name Imhotep is the most common variant and will be used in this biography. The pre-eminent American Egyptologist, James Henry Breasted, wrote of Imhotep, “In priestly wisdom, in magic, in the formulation of wise proverbs, in medicine and architecture, this remarkable figure of the Pharaoh Zoser’s (sic) reign left so notable a reputation that his name was never forgotten, and 2,500 years after his death he had become a God of Medicine, in whom the Greeks, who called him Imouthes, recognised their own Asclepius”4. One of the most famous Egyptian rulers, Djoser or Zoser lived from 2667 to 2648 BCE6.He is credited with by initiating the construction of the first successfully completed largest stone building in the world, the Step Pyramid at Saqqara (Sakkarah). However it was Imhotep the courtier who is now better known. For unlike Djoser, Imhotep became the object of a popular cult8.

In 1928, a statue-base was found during clearance work at the Step Pyramid bearing Imhotep’s name, and translates in ancient Egyptian to ‘the one that comes in peace’9. This identity would seem appropriate today for a man of healing bringing solace to the anxious patient. How he rose as a commoner to the highest post open to an Egyptian official is unknown. He may have been descended from a distinguished architect named Konofer and from a mother named Khreduonkh and he may have married Ronfrenofert. He appears to have received a liberal education and became a truly gifted polymath, a sort of Aristotelian genius10.

Why was he so enlightened? Pharaoh Djoser appointed Imhotep as the high priest of the sun god Re at Heliopolis the religious capital of Egypt11. He also became the chief lector (reader priest) or kheri-heb – a position of high esteem as he was considered by the populace as the mediator between the king and the unseen powers of the universe. The duty of the lector priest was to recite from holy books which contained religious texts possessed with magical powers. In this role as a magician he was supposed to influence the final destinies of the dead12. Imhotep was also one of Egypt’s great sages, a notable scribe and his literary skills led him to be recognised as the ‘patron of scribes’. It was, however, through his talents as a physician and as the chief architect that he achieved long-lasting historical significance. He was the court physician to King Djoser in addition to his appointment as vizier. The Edwin Smith Papyrus, c 16th century BCE, (a treatise on Egyptian medicine and surgery written in hieratic script) claims Imhotep to be the founder of Egyptian medicine. According to one examination of the Edwin Smith papyrus, it covers the treatment of over 200 diseases, including 15 diseases of the abdomen, 11 of the bladder, 10 of the rectum, 29 of the eyes and 18 of the skin, hair, nails and tongue. More recent analysis of the papyrus suggests that it was written and edited by at least three different authors and some consider it may be a copy of texts written a thousand years previously.13, The Art of Medicine evolved early in Egyptian history and developed to an unparalleled level of sophistication. Several ‘medical’ papyri have provided Egyptologists with detailed information as to the spectrum of Egyptian medicine. The

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two oldest ‘medical’ papyri are the Edwin Smith Papyrus (c 1600 BCE) and the Ebers Papyrus (c 1550 BCE). The latter, of over 20 meters in length, consists of a list of 876 prescriptions and remedies for such ailments as wounds, stomach complaints, cardiac diseases, gynaecological problems and skin irritations 14. The ‘London Medical Papyrus’ best describes the Egyptian approach to holistic healing. The tripartite strategy consists of magic spells, rituals and practical prescriptions. Pharmacological prescriptions by themselves were uncommon because many illnesses were regarded as the result of a malign spirit or god who had entered the body.15 The most common cure for maladies was probably the amulet, or the magic spell; magic was the ‘mother’ of medicine and never ceased to influence its ‘offspring’. The Egyptian physicianpriest-magician was skilled in suitable incantations, performed necromancy (divination through magical communication with the dead) and was skilful in making amulets adapted to the occasion.16 Whether a physician chose rational methods of treatment or white magic (‘theurgical’ treatment) such as invoking beneficent spirits was a matter of personal preference. Many faith-cures took place at famous shrines and temples 17. The practice of alchemy arose in Egypt, whose ancient name was khami. Egyptians studied metals including the ‘transmutation’ of copper and tin into the alloy bronze. The body of knowledge, which included these chemical reactions between metallic compounds, came to be known as al chemi, the art of Egypt. From the study of alchemy came the therapeutic use of copper salts, especially for ophthalmic use. Botanical studies of medicinal plants such as opium poppy, castor oil plants, squills (scillae) and lupins etc, enabled an extensive pharmacopoeia to be developed. Fuller’s earth, a form of clay, was also used topically on skin conditions. Splanchnology, which involved the scrutiny of animal entrails, especially the liver, was performed by priests in the temples. It was used as a means of divining the underlying meaning of events and foretelling the future. It involved the sacrifice of animals and their subsequent partial dissection and inspection.19 Hygiene was widely practiced with sanitation existing in many Egyptian towns and dwellings. Priests performed personal cleanliness by frequent ablutions (cold water washings twice a day and twice a night) and by the purity of their clothing20. Nonetheless, Egyptian medicine whilst quite advanced was never a science.

The Origins of Egyptian Military Medicine The empirical physician and surgeon were a lower caste of doctors called swnw (pronounced “soo-noo”) and were state employees appointed to building sites, at burial grounds or with the army. Egyptian sources indicate the development of military medicine in the Egyptian army with frequent descriptions of the treatment of battle wounds. They seem to have been the first to perfect the use of the splint for fractured bones, often stiffened by impregnated linen wrappings. These were introduced as early as 2600 BCE. A century later they developed techniques for treating depressed skull fractures. Egyptian physicians developed protocols for the treatment of wounds. This included the washing and debridement of the wound and removal of foreign bodies. Wound closure was introduced using string sutures or adhesive bandages consisting ADF Health | Vol 10 No. 1 | 2009

of linen cloth held together with resin from the gum of the acacia tree. Haemostasis was achieved using hot knife cautery. Wounds were then protected by wound dressings impregnated with a mild bacteriostatic agent, wild honey18. Honey was used in up to one third of all Egyptian treatments.

Imhotep the Engineer-Architect Whilst his healing and literary talents were well known, Imhotep also had great engineering and architectural skills. He put these to good use when he designed the first stone pyramid complex .Prior to Imhotep’s time, from c. 3,100 to 2686 BCE, Egyptian royal funerary monuments had taken the form of a mud-brick flat-topped buildings known as a mastaba. Imhotep’s complex consisted of a true pyramid with mortuary and attendant valley temples. The word pyramid is derived from the Greek word pyramis, meaning ‘wheat-cake’: they presumably resembled them in shape. The ancient Egyptian term for these burial monuments was mer21. At Saqqara (Sakkarah), the principal necropolis of ancient Memphis, Imhotep built a series of five progressively smaller mastaba on top of the original large limestone chamber to a height of 60 meters. The six-stepped pyramid, with its contained halls and corridors lined with blue and green glazed tiles bearing the king’s name and titles, became the tomb of his King Djoser 22. It was at the time the largest stone structure in the known world. The subsequent use of steps in pyramids, which continued to be constructed until the Intermediate Period of 1650-1550 BCE, was retained, and simply improved by the application of a smooth outer casing23.

The Apotheosis of Imhotep, the God of Healing Imhotep lived to an old age probably dying during the reign of King Huni, c 2637 to 2613 BCE, the last of the Third Dynasty rulers. The tomb of Imhotep has still not been discovered, although some have argued that it may be the large uninscribed mastaba 3518 at Saqqara24. Two thousand years later, Imhotep was deified and in the Turin Canon he became known as the son of Ptah, the creator-god of Memphis. As a god of wisdom, writing and medicine he became linked with the cults of the gods Thoth and Ptah. The Greeks identified him with their god of medicine, Asceplius (Latin: Aesculapius). Even before then the Oxyrhynchus Papyri, written in Greek in the second century AD, suggests that Imhotep was ranked as a demigod during the time of the New Kingdom, c 1580 BCE25 Admission of non-royal individuals to the Egyptian pantheon was exceptional and only two commoner-high officials are known to have earnt cult status. Imhotep together with Amenhotep, the son of Hapu and another great architect responsible to King Amenhotep III, c 1390 to 1352 BC, also regarded as a god of healing, ultimately received their apotheoses26. The worship of Imhotep lasted perhaps a thousand years.

Relics of Imhotep Numerous statues and statuettes of Imhotep have survived some showing him as an ordinary man dressed in plain attire. Others show him as a sage seated on a chair with a roll of papyrus on his knees27, as a demigod28 and with a god-like beard standing and holding the ankh, an hieroglyphic sign denoting ‘life’ depicted as a cross surmounted by a loop, and a sceptre29.

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Whilst later Western medical writers conferred the title, ‘Father of Medicine’, on Hippocrates, the Greek physician of the island of Cos (c 460 to 366 BCE), Imhotep preceded him. Arguably such an appellation should be reserved for the person, about whom the ancient Egyptian texts describe as, ‘Imhotep the great, son of Ptah, the great god’.

References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

Source: historiadelamedicina.org

25. 26. 27. 28. 29.

Osler W.The Evolution of Modern Medicine, Whitefish, MT: Kessinger Publishing, 2004:p.12. Ray J. Reflections of Osiris: Lives from Ancient Egypt, Oxford: Oxford University Press, 2002: p. 17. Hurry JB. Imhotep, Oxford: Oxford University Press, 1926: p.96-97. Breasted JH. A History of the Ancient Egyptians, New York: Scribner, 1909: p 104. Shaw I, Nicholson P. British Museum Dictionary of Ancient Egypt (London, British Museum Press, 1995: p 296-297. Shaw I, editor, ‘The Oxford History of Ancient Egypt’, (Oxford, Oxford University Press, 2000: p 480. Shaw I, Nicholson P. British Museum Dictionary of Ancient Egypt, op cit: p 169. Grimal N. A History of Ancient Egypt, English translation, Shaw I, Oxford, Blackwell, 1992: p 65. Ray J. Reflections of Osiris: Lives from Ancient Egypt, op cit: p15. Hurry JB, Imhotep, op cit. p 4. Moscati S. The Face of the Ancient Orient, London, Valentine, Mitchell & Co, 1960: p 103. Hurry JB. Imhotep, op cit: p 13-15. Peltier LF. Fractures: A History and Iconography of their Treatment, San Francisco Norman Publishing, 1990: p 16. Shaw I, Nicholson P. British Museum Dictionary of Ancient Egypt, op cit: p 176. Hurry JB. Imhotep, op cit. p 82. Ibid, p 82. Ibid, p 85. Gabriel RA and Metz KS. A History of Military Medicine, Volume I, New York, Greenwood Press, 1992. p 71–80. Camac CNB, Imhotep to Harvey, Boston, Milford House, 1931: p 26-28. Ray J. Reflections of Osiris, op cit: p 18. Ian Shaw and Paul Nicholson, ‘British Museum Dictionary of Ancient Egypt’, op cit. page 231. Jamieson B Hurry, ‘Imhotep’, op cit. page10. Callender G, ‘The Eye of Horus: A History of Ancient Egypt’, (Melbourne, Longman, 1993), pages 106 – 107. Shaw I, Nicholson P. British Museum Dictionary of Ancient Egypt, op cit p 135. Jamieson B Hurry, ‘Imhotep’, op cit. page 29. Callender G, ‘The Eye of Horus’, op cit. p 208. Shaw I, Nicholson P. British Museum Dictionary of Ancient Egypt, op cit p 135. Hurry JB, ‘Imhotep’, op cit. page 30. Ibid, frontispiece.

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HUMAN RIGHTS

Geneva: an ‘illusion of knowledge’ for ADF medical officers? CAPTAIN Mike O’Connor AM, RANR

Introduction CAPT Mike O’Connor is currently Editor of ADF Health and Surgical Professional Liaison Officer for the Naval Health Service. An obstetrician and gynaecologist in private practice, he also serves as Chairman of the Medical Advisory Committee at St George Private Hospital in Sydney .His military service commenced in 1976 in the RAMC (V) and continued in the RANR from 1982 until the present. He has served on HMAS TOBRUK, HMAS STALWART and HMAS MANOORA as well as in Bougainville and Timor L’Este. He is a consultant obstetrician and gynaecologist to the NAVY. Following completion of a Master in Health Law at Sydney University in 2008, CAPT O’Connor commenced a PhD in Medical Complicity in Torture at Sydney Law School That project involves an assessment of the knowledge of military physicians about humanitarian and human rights law.

The Geneva Conventions1 had their origins in the horrific suffering of wounded and dying combatants on the battlefield at Solferino in Italy2.Exactly one hundred and fifty years ago, Henri Dunant, a Swiss businessman, resolved to find a humane means of caring for these soldiers and his efforts finally led to the Geneva Conventions (GC’s). These four Conventions are international agreements on the humane treatment of wounded soldiers, ship wrecked sailors, prisoners of war and civilians caught up in armed conflict. All 191 States Members of the United Nations are Parties to the Geneva Conventions of 19493.There are two Additional Protocols (AP) which cover aspects of international armed conflict4 (AP1) and noninternational armed conflicts5(AP2).These two AP’s enjoy less than universal acceptance6: several major States such as the United States of America, for example, continue to hold reservations about the limited protection afforded to ‘illegal combatants’ by these AP’s. However Common Article 3 which is ‘common’ to all 4 Conventions already establishes a bare minimum of humane treatment for any combatant. In the first decade of the twenty first century non-international armed conflicts are the most prolific.

‘The greatest obstacle to discovery is not ignorance-it is the illusion of knowledge’.

Most military health personnel are aware that the GC’s provide protection from attack for them, their patients and their facilities. This includes a right to use small arms for self defence. Even when captured by enemy forces, health personnel are also entitled to special treatment in order to care for prisoners of war. The use of the Red Cross (or Red Crescent) symbol of protection on uniforms, health facilities and ambulances is subject to strict regulation and is limited to non warlike humanitarian activities7,8. The International Committee of the Red Cross was mandated by the international community to promote IHL and work for a better understanding of the law9.

Daniel J Boorstin. 1914-2004. American historian and attorney, Librarian of the United States Congress 1975-1987.

Abstract Generally medical students have little exposure to international humanitarian(IHL) and human rights law(IHRL). As medical officers in the Australian Defence Force (ADF) there are opportunities for selected officers to undergo such training however it is by no means universal and Reservists are probably least likely to receive such training. This paper argues that a baseline study of the current knowledge of Permanent and Reserve medical officers about IHL & IHRL is necessary. Those results will be helpful in determining if existing levels of understanding are adequate. New ways of delivering such education will be described.

The treatment of some enemy combatants in the ‘Global War on Terror’ has raised valid questions about the interpretation and application of the Law of Armed Conflict (LOAC) – a preferred term for IHL. These questions continue to be the subject of appeals to the US Supreme Court. In Hamdan v Rumsfeld10 the US Supreme Court held that even non- State illegal combatants such as al-Qaeda, who were not signatories to the Geneva Conventions, were nevertheless entitled to a basic minimum of humane treatment under Common Article 3 of the Geneva Conventions. That included protection from torture.

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Some aspects of International Human Rights Law (IHRL) are also relevant to the knowledge of military physicians, particularly those which prevent torture and cruel inhumane or degrading treatment of prisoners. The relevant conventions and declarations in IHRL include the Convention Against Torture11(CAT) and the International Covenant on Civil and Political Rights12 (ICCPR).Both prohibit torture. The 146 States that are Parties to the United Nations Convention on Torture 13 affirmed that torture should be, without exception, a criminal offence with appropriate penalties. In part it states that: No exceptional circumstances whatsoever, whether a state of war, or a threat of war, internal political instability or any other public emergency, may be invoked as a justification of torture14. To what extent (if at all) those Parties actually make it a prosecutable offence under domestic law is another matter. Common Article 3 of the Geneva Conventions15 and the International Covenant on Civil and Political Rights16 also prohibit the practice of torture. This ban on torture is absolute, even in times of war and it is non-derogable.

Contemporary problems with the respect for IHL & IHRL The abuse of prisoners in Abu Ghraib prison in Iraq by 372nd Military Police Company (US Army) appears to have involved the complicity of health personnel17. A description of torture in Abu Ghraib prison was published in the Lancet in 200418. This included failure by doctors to report physical evidence of torture, provision of confidential medical information to assist in interrogation techniques, reviving prisoners to enable continued torture and failing to maintain medical records of tortured inmates. The International Committee of the Red Cross ‘[f]ound that the medical system failed to maintain internment cards with medical information necessary to protect the detainees’ health as required by the Geneva Convention’19. Similar abuses have occurred in Bagram prison in Afghanistan20 where a US military medical officer confirmed the testimony of a tortured Iraqi detainee in October 2004. In 2004 the New England Journal of Medicine summarised the complicity of medical staff in torture in Iraq, Afghanistan and Guantanamo Bay21.The involvement of military physicians at Guantanimo Bay has further been documented by Jane Mayer22 and more recently by Philippe Sands23 who detailed the involvement by doctors in the continuous interrogation of Detainee 063 (Mohammed al-Qahtani) over a period of 54 days. Throughout that interrogation medical members of the Behavioral Consultation Teams provided intravenous hydration, enemas and biochemical monitoring. In September 2006 the ICRC visited Guantanamo Bay and interviewed 14 ‘high value detainees’ about the treatment by their captors. The Report24 indicated that twelve of the 14 detainees alleged that they had been subjected to ‘systematic physical and/or psychological ill-treatment’. The third part of this Report concerns the roles of health professionals who participated in the torture of these detainees. They monitored the oxygenation of a detainee (Kaled Sheik Mohammed, the ADF Health | Vol 10 No. 1 | 2009

architect of 9/11) who was being subjected to ‘waterboarding’ and halted the torture when oxygen levels dropped to lifethreatening levels. Other health professionals measured the degree of lower limb oedema during the torture of detainees who were subjected to prolonged stress positions. One detainee alleged that a health professional had threatened that his medical care was dependent on the subject’s cooperation with the interrogators. The ICRC reported instances of medical support for harsh interrogation techniques which caused bodily injury.

What do we know about IHL teaching? Few studies have been made on the knowledge and attitudes of doctors about human rights and international humanitarian law. However a large study conducted by the Indian Medical Association of 4,000 members chosen at random showed that of the 743 respondents 49% believed force feeding was justified, 37% believed solitary confinement was not torture and 58% believed coercive techniques might be justified to elicit information from uncooperative suspects. Interestingly, 16 % admitted to being witnesses to the infliction of torture and 18% confirmed that Indian doctors had knowingly participated in torture25. A second study in India 10 years later assessed the attitudes towards torture of 98 fourth year medical students26. When asked whether they approved of police beating suspects to obtain a confession or information, 48 (46%) were undecided and 28 (28%) agreed with such torture. In the United States of America 94% of medical students have less than one hour of teaching about military medical ethics or the Geneva Conventions27. In a survey of 8 US medical schools28 only 37.4% of undergraduate students correctly answered a question about the applicability of the Geneva Conventions in the absence of a declaration of war. More than a quarter of students (26.5%) incorrectly believed that wounded enemy soldiers should be triaged as a lower priority than wounded friendly forces instead of determining that priority by the severity of injuries. More than one third (37%) were ignorant of the prohibitions under the GC’s against depriving prisoners of food or water, exposure to thermal stresses, uncomfortable positions or threats of physical violence. In a scenario where a doctor was asked to inject a prisoner with a lethal or psychoactive or placebo (sham execution), 27% believed that they should comply with all but injecting a lethal drug and only 66% answered correctly that all 3 cases should be disobeyed. Those students with prior or current military service attained correct scores which were not significantly different from those medical students with no such exposure. Once graduated, military physicians are often ill equipped by unit preparation to deal with human rights issues. A 2005 Report from the US Army Medical Department29 revealed that 31% of 988 medical personnel believed they were inadequately prepared to ‘address human rights of detainees’ in Iraq, Afghanistan and Guantanamo Bay30. Pagaduan-Lopez et al contend that often doctors do not know about the standard minimum rules for the treatment of prisoners and assume that abuse is the norm in all jurisdictions(31). Maxwell and Pounder have attempted to address medical undergraduate ignorance of human rights using a self directed module32.Their two week optional module on Medicine and

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Human Rights was introduced at Dundee medical school in 1995.The module included knowledge of IHRL including compliance mechanisms as well as means by which doctors can be unwittingly drawn into human rights abuses. Overall the module aimed to develop student attitudes which respected human rights as an integral part of medical practice33. In Australia, Leitch and O’Connor have recommended that training of military health professionals in international humanitarian law be enhanced34. The ADF does provide IHL training to selected health professionals –for example such courses have been organised by ADF Legal Services at the Army Logistic Training Centre (ALTC), Bandiana - and as part of direct officer entry courses in all 3 Services. However such training is by no means universal and many senior medical officers, particularly in the Reserve branches, including the author have had no exposure to such military training. Without such knowledge, military health professionals are at an immediate disadvantage when ordered to support interrogation of prisoners which they suspect may breach the laws of armed conflict or human rights law.

ADF Proposals for Strengthening Ethical and Humane Treatment No official Defence Instructions-General [DI (G)]’s, guidelines specifically cover the education on LOAC or IHRL specifically for ADF military health professionals. Nor is there a DI (G) specifically on training ADF military health professionals generally. There is, however, a comprehensive system for training on LOAC within the ADF generally35. For example ADF legal officers’ competency in LOAC is achieved by their completion of:

tutorial on all the key subjects. c) The module could be easily and regularly updated by legal experts. d) On line education has inherent time and cost savings by avoiding lengthy and expensive campus based courses. e) completion of this module could be made a regular (say every 5 years) requirement for all ADF health personnel.

Concluding Remarks The 2009 Defence White Paper36 notes that: [I]nvestment in recruitment, training, education and the career development of the ADF’s junior personnel and leaders will continue to display substantial dividends in terms of our ability to achieve campaign objectives and reduced casualties, while maintaining the high ethical standards of ADF personnel, and the proud record of the ADF on operations37. The Centre for Military Leadership and Ethics at Joint Education, Training and Warfare Command now provides an opportunity for human rights to be debated more widely in Defence and in particular in the Australian Command and Staff College and Centre for Defence and Strategic Studies environments. This dialogue should include military health personnel who offer unique perspectives on the humane and impartial care of military personnel.

Endnotes 1.

Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field of August 12, 1949, opened for signature 12 August 1949, 75 UNTS 31 (entered into force 21 October 1950) (‘Geneva Convention I’); Geneva Convention for the Amelioration of the Condition of Wounded, Sick and Shipwrecked Members of the Armed Forces at Sea of August 12, 1949, opened for signature 12 August 1949, 75 UNTS 85 (entered into force 21 October 1950) (‘Geneva Convention II’); Geneva Convention relative to the Treatment of Prisoners of War of August 12, 1949, opened for signature 12 August 1949, 75 UNTS 135 (entered into force 21 October 1950) (‘Geneva Convention III’); Geneva Convention relative to the Protection of Civilian Persons in Time of War of August 12, 1949, opened for signature 12 August 1949, 75 UNTS 287 (entered into force 21 October 1950) (‘Geneva Convention IV’) (collectively, ‘Geneva Conventions’).

2.

International Committee of the Red Cross. ‘Henri Dunant (18281910)’.June 4 1998. http://www.icrc.org/Web/eng/siteeng0.nsf/ htmlall/57JNVQ accessed 30 August 2009

3.

International Committee of the Red Cross. States party to the Geneva Conventions and their Additional Protocols Geneva Conventions of 12 August 1949 and their Additional Protocols of 8 June 1977. http://www. aiipowmia.com/legis/protocoles.pdf accessed 30 August 2009

4.

Protocol Additional to the Geneva Conventions of 12 August 1949, and Relating to the Protection of Victims of International Armed Conflicts. Opened for signature 12 December 1977, 1125 UNTS 3, art 75 (entered into force 7 December 1978) (‘Additional Protocol I’).

5.

Protocol Additional to the Geneva Conventions of 12 August 1949, and Relating to the Protection of Victims of Non-International Armed Conflict. Opened for signature 12 December 1977, 1125 UNTS 609, art 4 (entered into force 7 December 1978) (‘Additional Protocol II’).

(a) Defence Legal task journals on Operations Law; (b) The ADF legal officer training programme (LTM1 – LTM3); (c) The accreditation requirements in DI(G) OPS 33-1 for legal advisers to military commanders While training in LOAC does not of itself cover all the issues that arise under IHRL, there is some degree of overlap suggesting that additional content on IHRL could be added to existing LOAC training to provide the necessary education for military health professionals. For military health professionals there is arguably a case for them to receive legal training which is focussed specifically on their needs. Within Joint Health Command the imminent baseline study of ADF doctor’s knowledge of IHL & IHRL should provide a snapshot of current understanding. It could prompt improvements to the way such education is delivered to a wider audience. The use of on line modules on IHL & IHRL is now possible. The ADF already has an on-line learning software package (CAMPUS) available on the DRN. An on line educational module would have the following advantages:

6.

There are 161 Parties to AP1 and 156 Parties to AP2. http://www. aiipowmia.com/legis/protocoles.pdf accessed 30 August 2009.

7.

a) The member’s current state of knowledge could be initially tested and with instant feed- back of those results.

François Bugnion. ‘The red cross and red crescent emblems’International Committee of the Red Cross. (31 October 1989) http://www.icrc.org/ Web/Eng/siteeng0.nsf/html/57JMB8 accessed 30 August 2009.

8.

Section 15(1) of the Geneva Conventions Act 1957 (Cth) provides that it is an offence to use any of the recognised emblems of the Red Cross movement, including the emblem of the Red Cross and Red Crescent. Katharine Philp. ‘Unauthorised use of the Red Cross emblem’ Tress

b) Deficiencies in the student’s understanding could then be addressed by access to a comprehensive referenced on-line

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Cox.Newsletter 2009 March 2. http://www.tresscox.com.au/resources/ resource.asp?id=432 accessed 3 Sep 09. 9.

International Committee of the Red Cross. ‘Direct participation in hostilities: questions & answers’ 2009 June 2. http://www.icrc.org/ web/eng/siteeng0.nsf/htmlall/direct-participation-ihl-faq-020609#a5 accessed 30 August 2009.

10. Hamdan v. Rumsfeld, 548 U.S. 557 (2006) 11. United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment Adopted and opened for signature, ratification and accession by General Assembly resolution 39/46 of 10 December1984. Entry into force 26 June 1987, in accordance with article 27 (1) U.N.T.S. 85 The United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment State Parties were required to prosecute perpetrators of torture and their accomplices (Article 5) and inform and teach their citizens, including the medical profession, about torture (Article 10).It requires States to provide regular reports to the Committee Against Torture (Committee) on their implementation of the provisions contained in the Charter. The Committee is a 10 member statutory United Nations committee. There are two notable States namely the United Kingdom of Great Britain and Northern Ireland and the United States of America who refused to sign Article 22. Under article 22, a State party to the Convention may acknowledge the authority of the Committee to investigate complaint of torture made against a member State. The absolute prohibition on torture contained in Article 2 has since become accepted as part of customary international law. Since 2006 an Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment, has been in force allowing “a system of regular visits undertaken by independent international and national bodies to places where people are deprived of their liberty, in order to prevent torture and other cruel, inhuman or degrading treatment or punishment,”11 Australia, China, Iran, Iraq, Russia and the United States have failed to sign or ratify this Optional Protocol. 12. United Nations General Assembly. International Covenant on Civil and Political Rights Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966 entry into force 23 March 1976, in accordance with Article 49. U.N.T.S. 171 13. United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment Adopted and opened for signature, ratification and accession by General Assembly resolution 39/46 of 10 December1984. Entry into force 26 June 1987, in accordance with article 27 (1) U.N.T.S. 85 < http://www.hrweb.org/legal/cat.html > accessed 27 August 2008

17. ‘Much of the evidence of abuse at the prison came from medical documents. Records and statements show doctors and medics reporting to the area of the prison where the abuse occurred several times to stitch wounds, tend to collapsed prisoners or see patients with bruised or reddened genitals. Kate Zernike, ‘The Reach of the War: The Witnesses; Only a Few Spoke Up on Abuse as Many Soldiers Stayed Silent’ New York Times. (22 May 2004). <http://query.nytimes.com/gst/fullpage.html?re s=9F00E6D91F3FF931A15756C0A9629C8B63&sec=&spon=&pagewante d=2> accessed 31 August 2008 18. Miles SH. Abu Ghraib: its legacy for military medicine. Lancet 2004 364: 725-729. 19. International Committee of the Red Cross. Report of the International Committee of the Red Cross on the Treatment by the Coalition Forces of Prisoners of War and Other Protected Persons by the Geneva Convention in Iraq during Arrest, Internment, and Interrogation. Feb 2004. <http://www.globalsecurity.org/military/library/report/2004/ icrc_report_iraq_feb2004.htm> accessed 31 August 2008 20. Meek J. Papers reveal Bagram abuse. The Guardian 2005 Feb 18. <http://www.guardian.co.uk/world/2005/feb/18/usa.iraq> accessed 31 August 09 21. Lifton RJ. Doctors and Torture. NEJM 2004:351:415-416. <http:// content.nejm.org/cgi/content/full/351/5/415> accessed 31 August 2008 22. Mayer J. The Experiment: The Military Trains People to Withstand Interrogation — Are Those Methods being Misused at Guantánamo? The New Yorker 2005 July 11. http://www.newyorker.com/ archive/2005/07/11/050711fa_fact4 accessed 3 Sep 09. 23. Sands P. Torture Team, London, Allen Lane, 2008 at 206. 24. International Committee of the Red Cross, Report on the Treatment of Fourteen ‘High Value’ Detainees in CIA Custody 2007 February). 25.

Jagdish Sobti, Chaparwal B, Choudhary PK, Erik Holst, Bhatnagar NK. Knowledge, attitude and practice of physicians in India concerning medical aspects of torture. New Delhi Indian Medical Association; 1996.

26. Verma SK, Biswas G. Knowledge and attitude on torture by medical students in Delhi. Torture 2005; 15: 46-50. 27. O’Rielly KB. Future doctors flunk military medical ethics test. American Medical News 2007 Dec 17. http://www.ama-assn.org/ amednews/2007/12/17/prsb1217.htm accessed 28 Feb 2009 28. Boyd JW, Himmelstein DU, Lasser K, McCormick D, Bohr DH, Cutrona SL, Woolhandler S. U.S. Medical Students’ Knowledge About The Military Draft, The Geneva Conventions and Military Medical Ethics International Journal of Health Services 2007; 37:643-650.

14. Article 2(2) of the U.N. Convention against Torture http://www.hrweb. org/legal/cat.html accessed 10 September 2008

29. Office of the Surgeon General, Assessment of detainee medical operations for OEF,GTMO and OIF (2005)

15. Geneva Convention relative to the Treatment of Prisoners of War 12 August 1949 Geneva , Common Article3 ‘In the case of armed conflict not of an international character occurring in the territory of one of the High Contracting Parties, each party to the conflict shall be bound to apply, as a minimum, the following provisions: 1. Persons taking no active part in the hostilities, including members of armed forces who have laid down their arms and those placed hors de combat by sickness, wounds, detention, or any other cause, shall in all circumstances be treated humanely, without any adverse distinction founded on race, colour, religion or faith, sex, birth or wealth, or any other similar criteria. To this end the following acts are and shall remain prohibited at any time and in any place whatsoever with respect to the above-mentioned persons: (a) Violence to life and person, in particular murder of all kinds, mutilation, cruel treatment and torture; (b) Taking of hostages; (c) Outrages upon personal dignity, in particular, humiliating and degrading treatment; (d) The passing of sentences and the carrying out of executions without previous judgment pronounced by a regularly constituted court affording all the judicial guarantees which are recognized as indispensable by civilized peoples.

30. Jesper Sonntag,’ Doctors’ involvement in torture’ (2008) 18 Torture 161-175.

16. United Nations General Assembly. International Covenant on Civil and Political Rights Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966 entry into force 23 March 1976, in accordance with Article 49. U.N.T.S. 171 Article 7:‘No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. In particular, no one shall be subjected without his free consent to medical or scientific experimentation’ ADF Health | Vol 10 No. 1 | 2009

31. Pagaduan-Lopez J, Aguilar AS, Castro MCR, Eleazar JG, McDonald A, Schweickart AP. Crossing the line: a nationwide survey on the knowledge, attitudes and practices of physicians regarding torture. Psychosocial Trauma Quarterly 1997(Jan-Mar): 21-2. 32. Rachel Maxwell and Derek Pounder, ‘The medicine and human rights special study module A Physicians for Human Rights (UK) initiative’ Medical Teacher 1999; 21: 294-298. 33. Id 34. Leitch R, O’Connor MC.Appropriate Medical Monitoring? ADF Health 2005; 6: 15-18. 35. See DI (G) OPS 33-1 and ADDP06.4 – Law of Armed Conflict. These deal with some, but not all, issues affecting military health professionals in issues related to LOAC and IHRL. Significantly, clause 8 of DI (G) OPS 33-1 provides that “ADF members are to be trained [in LOAC] to the level of understanding appropriate for their duties and responsibilities.” [Insert added; emphasis added]. Clause 6 of DI (G) OPS 33-1 provides that the training adviser for LOAC training in the ADF is the DirectorGeneral of Defence Force Legal Services. The Service Chiefs are responsible for LOAC training and consequences of any breaches of LOAC, and the Directors of each Service’s legal services are to provide their service’s with legal support, including training (Clauses 11-15). 36. Australian Defence Force. Defending Australia in the Asia Pacific Century: Force 2030 at 8.70. http://www.defence.gov.au/whitepaper/ docs/defence_white_paper_2009.pdf accessed 30 August 2009. 37. Id

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ADVERTORIAL

Advanced Dental Laser Surgery Dr. Rudolf Walker, Dr. Gerd Volland, Germany

T

he laser application in dental surgery has become a standard tool for many dental clinics around the world. The instrumentation became less costly and more advanced. The use of a diode laser demonstrates many advantages compared to the scalpel, but as in life one has to deal with some disadvantages also. One of the main hurdles has been the price and the teaching about laser applications in dentistry. Fig. 1 Fox with sapphire knife (Jazz)

Fig. 2 Sapphire knife (side view).

The main advantages for the laser are the cutting effect on tissue at the same time tissue is removed and bleeding is almost stopped. By using the laser beam in the bare fiber mode one of the disadvantages is the temperature rise at the edges of the wound. Due to this effect the wound healing is prolonged in comparison to the standard scalpel cut. Those edges do show a carbonization zone, which is responsible for the prolonged healing time.

However to achieve proper cutting the surgeon has to apply enough leaser energy to cut and vaporize tissue. To overcome the prolonged healing the stitches have to be in the wound longer than it would be compared to the standard scalpel cuts.

and no cleaning of the wound is required during surgery. Higher visibility at the cuts and faster healing compared to the laser cuts are the results of this exiting invention. (Abb. 3 to 6) Using this knife during the last month we have demonstrated the superiority of this technique. The very first tests have been performed using a pork liver to research the cuts and look at the histology of the wound edges. The histology has proven that the edges do not show any major necroses zones. The cuts are clean with minimal demonstrations of heat been applied. To compare those cuts with the standard free beam laser cuts, one can immediately see the difference. The large necrosis zones with the laser are highly visible and therefore lead to the prolonged healing time, whereas the cuts with our new JAZZ are clean and almost comparable to the standard scalpel cuts. (Figs. 7 and 8) n For more information on the FOX Diode Laser or Jazz Sapphire Scalpel, contact: Paul Baltas Innovative Medical Technologies Pty Ltd 101 Atherton Road, Oakleigh VIC 3166 Australia Telephone: 1800 88 983 Fax: 03 9569 5549 Email: paulb@inmedtec.com

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

With the electro cauter the edges of the wound are even more coagulated than with the laser beam. The wound healing does show the same effect like the laser cuts. The patient has the advantages of the laser cut, however has to accept the longer wound healing. To avoid all those disadvantages we have developed a scalpel which carries the laser energy from the diode laser to the sharp edges of this knife. This sapphire knife was developed in cooperation with surgeons working daily with this new technology now. As a producer of the FOX diode laser we have developed this knife to overcome the problems of the free beam laser and also the problem of cutting with the scalpel alone. (Fig. 1)The revolution is the coagulating, cutting knife. The scalpel can be used as a standard surgical knife with all the advantages of the tactile feedback, but at the same time having the laser to coagulate at the sharp edges. The laser light exits the knife at the edges where it cuts. (Fig. 2) The temperatures achieved with the sapphire knife are in the range of > 65째 to allow coagulation, but less then 100째 to avoid carbonization. The cut is only performed by the knife itself. To allow the laser to exit at the right edges a mathematical calculation has been performed for maximum transmission and reflection inside the knife. Thus the absorption inside the knife is minimal and no temperature rise at the handle is produced. The result is a cut which is almost free of bleeding

Fig. 3-6 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8

Patient 75 years lower jaw Implants with recurring inflammation at the implant (regio 33). Initial situation Missing attached gingival at implant regio 33. Vestibulum plastic cuts with lateral denaturation. Deep cut: muscle cut in two and inlaying strands pre suturing. First day post OP. Prosthesis was immediately prolonged at the edge. Fibrin eschar. Patient without pain and complains. Cut in a liver using the Jazz. Reference cut with a free laser beam into a liver.

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Obituary

Veritas, Scientia et Misericordia

MAJOR GENERAL SIR WILLIAM DUDLEY REFSHAUGE Kt B, AC CBE ED MID**** MBBS FRCOG FRACS FRACP FRACMA FRACOG FRSH (Hons) MD (Hons causa) VX220, RAAMC

3 April 1913 – 27 May 2009

Australian War Memorial Negative Number 074520

Soldier, Clinician, Administrator, Athlete and Diplomat

‘As a regimental medical officer in the horrendous campaigns of Greece and Crete, Sir William served with forward units, and understood very well the difficulties faced by medical officers working in isolation in forward areas. He worked in difficult circumstances during the Greece campaign, often not knowing where and when he would expect his casualties to be evacuated”.1

O

n the 27 May 09 a great Australian military physician died in his 97th year. Sir William rose from harsh beginnings at his widowed mother’s dairy farm north-west of Melbourne during the Great Depression, to become Chairman of the Executive Board of the World Health Organisation in Geneva, and a Knight of the Realm. It was a remarkable history of public service in both war and peace.

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Much of his history is already in the public domain2,3. Some of the crucial elements have not been told. Eighteen years ago Sir William revealed some of these extraordinary details in a private communiqué to his family, particularly his role as a junior and middle-ranked medical officer with the AIF in World War II4. He saw active service in at least seven theatres, both on land and at sea (Bardia, Greece (Veria Pass, Servia Pass, and Brallos Pass), Mediterranean (twice), Crete, Ceylon, Milne Bay, Wau, Salamaua, Ramu Valley and Borneo). He sustained battle injuries on two successive days under heavy air bombardment in Crete, and succumbed to tropical diseases in PNG. He found himself effectively behind enemy lines twice :on one occasion, rescuing a badly wounded colleague from an Italian Field Hospital5.He was Mentioned in Dispatches on four occasions, and was awarded the Order of the British Empire (OBE) for his leadership of medical services in Wau and Mubo. In wartime, he made significant contributions to logistics, blood transfusion and resuscitation, aero-medical evacuation, preventive medicine and the management of ex POWs. His interaction with the Executive Branch of the Army was frequently challenging, but always professional. His “Notes for RMOs” published in 1943, are just as relevant for junior ADF health officers today. Following World War II, he had a long and distinguished career as an Obstetrician/Gynaecologist, Director General Army Health Service (DGAHS), Commonwealth Director General of Health, Secretary General of the World Medical Association and Chairman, Executive Board of the World Health Organisation (Geneva). His interests and expertise covered the spectrum of neonatal medicine through to nuclear weapons and the effects of radiation (he attended the nuclear tests at Einiwetok and Bikini as the Australian Army representative (1957/58), infectious diseases (tuberculosis), the role of the Red Cross, post traumatic stress disorder and substance abuse. He had a life-long interest in the welfare of veterans. Of all his combat experiences, none affected him more than those in Crete. Though reluctant to discuss it openly, the experience would dominate his thinking for the rest of his career. Sir William was leading his Regimental Aid Post (RAP) in support of his regiment (2/2nd Field) in May 1941 near the cross-roads at Mournies, just south of Canea. Already personally injured in a bombing raid from the previous day, Refshauge’s unmarked RAP was subjected to another raid by Stuka dive bombers. His senior medical sergeant (Vincent) was killed instantly, as was his mess orderly who was lying next to him in a shallow ditch. Two of his other medical orderlies (Donovan and Findlay) received the Military Medal for their work with the wounded survivors under his direction. Refshauge was badly concussed by flying debris but still tended to the dying and wounded. He was Mentioned in Dispatches for that bravery. He then accompanied his regiment in a grueling 24 hour march across the mountains to a beach on the southern coast of Crete. Vessels from the Royal Navy and ADF Health | Vol 10 No. 1 | 2009

Royal Australian Navy evacuated his unit under further air attack and transported them to Alexandria. His colleague, Lt Colonel Le Souef of the 2/7th Field Ambulance along with several of his men, failed in their attempt to escape and spent the rest of the war as POW’s6. Sir William’s youngest brother, (John Refshauge AM OBE) was a fighter pilot with the RAF and was shot down over Normandy in 1944.He survived and became an ENT surgeon in Melbourne. As DGAHS, Refshauge was instrumental in founding the School of Army Health (at Healesville, Victoria).It was subsequently transferred to Point Nepean (Portsea) and thence to Bonegilla. In 1971, he chaired a Committee of Inquiry into the Integration of the Medical Services of the Armed Forces (the Refshauge report)7. Ultimately most of his recommendations were incorporated into the role of the Joint Health Commander / Surgeon General ADF in July 2008. Sir William died in Canberra, on the 27th May 2009 and was buried with full military honours. He was pre-deceased by his wife, (Lady Helen), and his four siblings. Sir William is survived by his five children and their grandchildren. A full account of his life waits to be written.

M. J. Flynn CDRE RAN (Ret’d) 30th September 2009 Published with the kind permission of Dr Andrew Refshauge and other members of the family, and Ms A. W. Bundock, coauthor of Truth, Knowledge and Compassion.

References 1.

2. 3.

4.

5. 6. 7.

The ADF Eulogy led by Surgeon General Australian Defence Force, Major General Paul Alexander at the Funeral Service for the Late Major General William Dudley Refshauge, 3rd June 2009. http://en.wikipedia.org/wiki/William_Refshauge - accessed 14th September 2009 A series of interviews with Terry Colhoun was subsequently recorded in 2000 and is available through the National Library of Australia – Bib ID 1897835 “Truth, Knowledge, Compassion - Memoirs of W. D. Refshauge 1930 – 1960” – Copyright – Sir William Refshauge & A. W. Bundock, Canberra 1996 Tyquin M, Little by Little (Australian Military History Publications – 2003) p 327 Tyquin M, Little by Little (Australian Military History Publications – 2003) p 347 Report of Committee of Inquiry into Integration of the Medical Services of the Armed Forces; W.D. Refshauge, F.O. Chilton, S Sunderland, H. D. Raffan, L. R. Trudinger, 1st March 1971

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Letter to the Editor

TO THE EDITOR: In 2007, McLean et al discussed the use of tourniquets to control major peripheral haemorrhage1 .This is a particular problem in blast wounds sustained from Improvised Explosive Devices (IED). CDRE Walker responded to that article, noting that the Combat Application Tourniquet (CAT) was introduced into operational environments in 20062. Guidance on their use was contained in Defence Health Bulletin 4/20063. Whilst this guideline does supply information on the indications for the use of CAT’s Maclean et al claimed that it lacks information on the technique of field application. Policies vary on the correct application of military tourniquets - ranging from certain distances ‘above the lesion,’ (as with the ADF) through to ‘high and tight.’ Some guidelines condone the use of tourniquets below the elbow or knee, despite the common practice in orthopaedic surgery to only use tourniquets on single long bones. No direction exists in the current ADF policy. The time when tourniquets should be applied also varies - from early application through to “a last resort to save life” as with the ADF. Further research is indicated to identify the ideal positioning and timing for tourniquet application. There are two main scenarios for use of the Combat Application Tourniquet. Both involve harsh environments with medics or first aiders in attendance. In the ADF’s current operations the injuries are usually the result of detonation of an improvised explosive device with no other hostile threats in the vicinity or during engagement with enemy forces –so called ‘CareUnder-Fire” (CUF). The ADF policy does mention that CAT’s can be used occur when ‘operational circumstances preclude conventional management’ and for CUF this technique excels.

Combat caregivers have limited ability to assess and treat their patients and salvage needs to occur whilst a mission proceeds. When this is the case tourniquets should be applied ‘high and tight’ as soon as possible, with review once the scenario allows. Coalition forces in the Middle East are already employing this strategy and ADF policy should be amended to reflect this. Nicholas L. Gray CAPT RAAMC Regimental Medical Officer, Force Support Unit – 1, Middle East Area of Operations nicholas.gray@defence.gov.au

References 1.

McLean JM, Atkinson R, Mooney L, Lovett D, The use of tourniquets in the Australian Defence Force. ADF Health 2007; 8: 70-75

2.

Walker R. To The Editor: The use of tourniquets in the Australian Defence Force. ADF Health 2008; 9: 48

3.

Defence Health Bulletin 4/2006. Combat Application Tourniquet – use in the ADF. 24 March 2006

Editorial Comment BRIG A Gill has indicated that these concerns have been addressed in Health Directive 704 Combat Application Tourniquet™ _ Instructions for use in the Australian Defence Force dated 17 Sep 09. Letters to the Editor are strongly encouraged.

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 Service Email: brendan.byrne@defence.gov.au Fax: (02) 6266 2143 Post: 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.

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