ADF Health

ADF Health

Journal of the Australian Defence Health Service

STRENGTHENING HEALTH IN DEFENCE

VOLUME 12, NUMBER 1

2011

ADF Health

Journal of the Australian Defence Health Service

STRENGTHENING HEALTH IN DEFENCE

Contents 3 Editorial: CAPT Mike O’Connor 5 Guest Editorial MAJGEN Paul Alexander AO 7 Guest Editorial MAJGEN Jeff Rosenfeld AM 11 Inaugural Chair of Military Medicine & Surgery LTCOL Michael C. Reade

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Honours and Awards Review of fluid resuscitation and massive transfusion protocols from a military perspective Capt Thileepan Naren, COL Alistair Royse, LTCOL Michael C. Reade

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Primary Headache Management In Military Medicine

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Radiation hazards and fertility. What do we know?

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Clinical Quiz A Soldier with Fever and a Rash

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Readership Survey

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CMDR Roy G Beran

LCDR Steve Robson

LtCol Peter A. Leggat

Strategic reform of deployable mental health support CMDR Geoff Waghorn

Townsville field training area health assessment

LT Ben M. Brumpton, CAPT Brady A. McPherson, MAJ Stephen P. Frances, MAJ Timothy J.J. Inglis, COL Bradley J. McCall

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A Vision for Indonesia Col John Crompton

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The Heritage of Naval Surgery LCDR Noel Tait

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Sir William Williams Prize MAJ Michael Tyquin

Tactical Aeromedical Evacuation CMDR Bruce L Greig Fitness to Serve Steven Sponberg, Capt Mike O’Connor, Brig Stephan Rudzki

Strategies for Regulating and Improving the Conduct of Military Physicians CAPT Mike O’Connor Letter to the Editor CAPT David Heslop

Front Cover: 9 minutes after the incident. on Suspected Illegal Entry Vessel (SIEV) 36 Medical Officer Flight Lieutenant

Jo Darby treats a casualty on Childers’ quarter deck as a RHIB approaches with survivors. At around 8:15 am (AEDT) Thursday 16 Apr 09 there was an explosion onboard a suspected illegal entry vessel that was intercepted the previous day in the vicinity of Ashmore Reef. HMA Ships Childers and Albany recovered all survivors from the water. Medical assistance was rendered by ADF personnel via triage to casualties. Headquarters Northern Command (HQNORCOM) arranged casualty evacuation, supported by the WA and NT State and Commonwealth agencies. Air Force AP-3C Orion and Customs and Border Protection DASH 8 aircraft conducted a search and rescue operation for two missing persons under the control of Australian Maritime Safety Authority – Rescue Coordination Centre. The Patrol Boats proceeded to the Front Puffin for casualty evacuation. An AP-3C Orion conducted a box-drop of additional medical supplies to the Patrol Boats. A medical triage facility was established at Truscott Airfield and on the Front Puffin for high priority casualties. Casualties were transferred from the Front Puffin to Truscott by CSC helicopter. At Truscott casualties were again triaged and flown to specialist facilities in Darwin, Broome, Perth or Brisbane for medical treatment. HMAS Albany was met on arrival in Darwin at 1:30 pm (AEDT) 17 Apr 09 by paramedical and other government agency staff to assist the casualty reception. HMAS Childers arrived in Darwin at 4:30 pm (AEDT).

ADF Health | Vol 12 No. 1 | 2011

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

Editorial Board Chairman, Editorial Board Major General Jeffrey V Rosenfeld AM MBBS(Melb), MD(Monash), MS(Melb), FRACS, FRCS(Edin), FACS, FRCS(Glasg)Hon, FCNST Hon, FRCST Hon, FACTM, MRACMA Surgeon General Defence Health Reserves Editor: Captain Mike O’Connor AM, MB BS (Hons), MHL,MD, DCH, DDU, FRCOG, FRANZCOG,FACLM, JP, RANR Assistant Editors Lieutenant Colonel K.L. Clifford RN, GradCertEmerg, GradDipMid, MHA, MPH, MRCNA, MCN, FCHSM, RAANC Group Captain A.C. McFarlane AO MB BS (Hons), MD, Dip. Psychother, FRANZCP RAAFSR Lieutenant Commander Steve Rayner MA, M Clin Psych, PhD, RANR, Professor G.D. Shanks BS, MD, MPH, FACTM, Director Army Malaria Institute Major M.B. Tyquin PhD, BEc, BA (Hons), MStJ, MPHA Editorial Consultants Major General J.H. Pearn (Ret’d) AO, RFD, MD, M Phil (Qld) BSc, PhD, FRACP, FRCP, FACTM, FAIM Air Vice Marshal B.H. Short (Ret’d) AM, RFD, MB BS, MA (Syd), FRACP, FCCP, FACP, FACTM Production Manager Sonya Murphy Publication Administrator Captain Brendan Byrne BDS, MMDS, MBA, Grad Dip MS, psc (j) RAN, 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

Adbourne Publishing Pty Ltd PO Box 735, Belgrave, Victoria 3160 Tel: (03) 9758 1433 Web: www.adbourne.com Email: production@adbourne.com

ADF Health | Vol 12 No. 1 | 2011

Editorial

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his edition of ADF Health marks the end of 2 most influential appointments: MAJGEN Paul Alexander AO, Joint Health Commander and MAJGEN Jeff Rosenfeld AM Surgeon General (Reserves). The Editorial Board plays tribute to these two senior officers who have richly contributed to JHC. The Journal continues to be well supported by prospective authors however a decision has been taken to encourage younger authors to write for the Journal. The new Sir William Williams prize will be awarded annually from 2012 to the most promising author of Major equivalent and below. You will find in the centerfold a short questionnaire which surveys again readership opinion. This is an important inquiry which will help to shape future Journals. I encourage you to participate and so enter a draw for a substantial cash prize. Contained in this Journal are papers on fluid replacement (Reade et al), the new Medical Employment Classification introduced on July 1, 2011 (Sponberg et al), AME practical advice (Greig), a tropical medicine quiz (Leggatt), a personal viewpoint on changes necessary for deployed mental health teams (Waghorn), a review article on headache in the ADF (Beran), the effects of RADHAZ on fertility (Robson), and an inspiring short report on ophthalmic outreach assistance to Indonesia by the John Fawcett Foundation. A health assessment of risks in the Townsville Training Area has been reported in some detail. There is a historical perspective on Naval surgeons and their heritage (Tait). O’Connor has offered a personal view on regulating and improving the performance of ADF medical officers. Both MAJGEN Alexander and MAJGEN Rosenfeld have contributed some parting observations on the state of Joint Health Command. LTCOL Reade has offered some vision for the new Chair of Military Medicine and Surgery. ADF Health welcomes the announced appointments of RADM Robyn Walker AM as Joint Health Commander and AVM Hugh Bartholomeusz OAM as Surgeon General Defence Health Reserves with effect December 2011. I wish to acknowledge the valuable assistance I have received from other members of the Editorial Board: in particular continues next page >

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EDITOR’S MESSAGE ADF Health welcomes the appointment of RADM Robyn Walker AM as Joint Health Commander and AVM Hugh Bartholomeusz OAM as Surgeon General Defence Health Reserves. MAJ Mike Tyquin, AVM Bruce Short (Ret’d), LCDR Steve Rayner, Prof Dennis Shanks, GPCAPT Sandy McFarlane, GPCAPT Dave Scott, COL Tony Delaney, RADM Graeme Shirtley, LCDR Stuart Lowe as well as the staff of Adbourne Publishing. I thank all those authors who have taken the time to carefully prepare papers for publication in this edition. Readers are strongly encouraged to contribute relevant articles for future editions.

Mike O’Connor

CAPTAIN Mike O’Connor AM RANR MD DCH DDU FRCOG FRANZCOG MHL FACLM

Captain O’Connor is the current Editor of ADF Health and a practising obstetrician and gynaecologist. His role in Navy is as the Surgical Professional Liaison Officer and he is responsible for approximately 30 Navy surgeons. CAPT O’Connor is Chairman of the Chapter of Military Obstetrics and Gynaecology in the RANZCOG and conducts annual courses for Deploying Surgeons in Emergency Obstetrics and Gynaecology. Over 100 health personnel from all 3 Services have now completed that course. His original research was in perinatal asphyxia but he now is involved in legal research on medical complicity in torture. He also has extensive experience in medico legal work as an expert witness. He currently acts as Chairman of the Patient Care Review Committee at St George Private Hospital in Sydney.

Editor, ADF Health

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ADF Health | Vol 12 No. 1 | 2011

guest editorial

Major General Paul Alexander AO Surgeon General Australian Defence Force and Commander, Joint Health Command

MAJGEN Paul Alexander joined the Army in 1976 and completed his medical training at the University of Melbourne in 1978. Following several years of clinical training in Victorian hospitals, he commenced the first of several regimental appointments as the Regimental Medical Officer (RMO) of the 3rd Battalion Royal Australian Regiment. This was followed by several years working as an RMO in Papua New Guinea with the PNG Defence Force. He then served as the RMO for the Special Air Service Regiment for three years and completed SAS selection during his tenure. In 1988 he undertook a period of postgraduate medical training in the UK in the areas of Sports Medicine and Tropical Medicine as well as undertaking several military attachments with UK medical units. On return to Australia he was promoted to Lieutenant Colonel and appointed as Commanding Officer of 11th Field Ambulance and subsequently as Commanding Officer of 1st Military Hospital Yeronga. Three years were then spent with the US Army as the Australian Army Exchange Officer to the US Army Medical Department where he was employed in the area of Capabilities, Combat and Doctrine Development and was involved in the redevelopment of US Army battlefield hospital systems. On return to Australia he was promoted to Colonel and posted to Headquarters 1st Division as the Senior Medical Officer and during this period, deployed with the initial peacekeeping force to Bougainville on Op BELISI. He transferred to the Army Reserve in 1998 and subsequently assumed the position of Director Reserve Health Services for Army in QLD. During this period he deployed as the Public Health Officer to the UN Peace Keeping Force in East Timor. He was promoted to Brigadier in January 2004 and assumed the position of Assistant Surgeon General ADF - Army. He continued to work in clinical practice and was a partner in a large group medical practice in Queensland, undertaking the duties of managing partner. He was active in primary health care policy development as the Chairman of the Redcliffe Division of General Practice. MAJGEN Alexander has been actively involved in risk management and legal medicine. He is a Fellow of the Australian College of Legal Medicine, a fellow of the Australian College of Medical Administration and also a fellow of the Australian College of Tropical Medicine. MAJGEN Alexander was promoted to the rank of Major General on 25th March 2008 and recommenced full time service. MAJGEN Alexander was appointed Commander Joint Health and Surgeon General Australian Defence Force on 4 August 2008. Joint Health Command was established in August 2008 and has been responsible for leading the Defence Health Services Reform programs. Major General Alexander was appointed an Officer of the Order of Australia on 26 January 2011.

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As I come to the end of my tenure as Commander Joint Health Command I am pleased that there has been significant headway in many of the reforms endorsed by the Chiefs of Service Committee. I believe the Defence Health services are in a very good position to ensure that our members receive comprehensive high quality health care. I have listed some of our achievements below; however the provision of first-rate health support to the ADF is a highly valued condition of service and cannot be underestimated. I applaud the staff of Joint Health Command for their caring attitude and professional services. Since my last editorial, Joint Health Command (JHC) has signed agreements with the Navy, Army, Air Force and the Defence Support Group to assume the delivery of Garrison Health Services. Transition to JHC will be carried out in stages, one region at a time, and we are aiming to have all five regions transitioned to JHC at the beginning of 2012. The nine Area Health Services are consolidated in to five Regional Health Services to align with DSG. Each region is led by a Regional Health Director who are highly qualified and bring extensive medical and Defence experience to their appointments. They have already begun to positively impact and improve the operations of our health services. Furthermore, JHC have reviewed the Garrison Health Delivery Model and established new ways to deliver health services through multi-disciplinary teams. JHC are moving toward an approach where ADF members can receive primary health care, mental health, rehabilitation and dental services in one convenient and coordinated health precinct one each base, nationwide. This will improve and simplify how ADF members access health care services. A comprehensive Strategic Infrastructure Plan for Defence Health facilities has been endorsed. This plan is the end result of significant research and analysis, and also the driver of a more integrated, streamlined and collaborative approach to our infrastructure improvement. It will take some years to implement completely, so we are upgrading some of the facilities in the short term. We have commenced working on a pilot program offering specialist training opportunities for Medical Officers. The program will be conducted at the Royal Brisbane and Women’s Hospital (RBWH) in alliance with Queensland Health. A total of five accredited specialist training positions will be offered

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in anaesthetics, emergency medicine, intensive care, general surgery (trauma/burns) and orthopaedics commencing in 2012. On completion of specialist training our Medical Officers will continue to be employed in major teaching hospitals, available for operational deployment, education, training of our health personnel and research.

mental health treatment. Through the Centre, JHC is building a range of partnerships with other centres of excellence in the civilian community to ensure that ADF mental health providers are trained in the latest mental health interventions.

I am pleased to announce the appointment of Professor Michael Reade as the inaugural Chair of Military Surgery and Medicine at the University of Queensland. Professor Reade will focus on the unique requirement of Defence in pre-hospital care, burns, damage control, resuscitation and surgery and will be pivotal in implementing our research priorities.

We have invested in a series of research studies and surveys under the Military Health Outcomes Program (MilHOP). These studies will give us better understanding of the prevalence of mental health conditions such as Post Traumatic Stress Disorder amongst our serving personnel and identify what barriers there may be in ADF personnel seeking mental health care. Importantly, the studies will consider the impact of operations and provide a benchmark for ongoing analysis.

JHC continues to put into operation a comprehensive Mental Health Reform Program to address the recommendations of the review completed by Professor David Dunt in February 2009. A new branch was established in 2010 within JHC with a Director General appointed to coordinate and integrate Mental Health, Psychology and Rehabilitation services. This branch developed the ADF Mental Health Plan and service delivery model. The plan is providing a framework for future mental health initiatives and the ongoing evaluation of programs and services.

JHC is acutely aware of the need to not only change the way we deliver services but also develop and realize a number of innovative and best practice health solutions. Joint E-Health Data and Information (JeHDI) system is progressing to plan with the completion of Stage 1. The project is now building the system. I wish to thank all the staff involved in the Solution Demonstration Laboratories as these workshops were vital part of ensuring that we develop the best product. JeHDI remains on track for release in 2013.

A major focus of this reform program is increasing our mental health and rehabilitation provider workforce. These teams will deliver a greater level of integrated care and mental health research. The mental health workforce has increased by more than 50%; fifty-six new positions have been established at the national, regional and local levels, with more to follow in 2012.

It has been a real privilege to again serve full time and I wish to personally thank everyone for their great support over the past three and a half years or more. I have really enjoyed the challenges and truly believe we are developing a military health system that is the equal of any. I wish to congratulate the new Commander Joint Health Command, Rear Admiral Robyn Walker on her appointment and I am sure that she will lead the command to greater success.

The ADF Centre for Mental Health will also support the development and application of effective and evidence based

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guest editorial

Major General Jeffrey Rosenfeld AM Surgeon General Defence Health Reserves

Reflections Major General Jeffrey Victor Rosenfeld joined the Australian Defence Force in 1984 as a Direct Entry Officer. His postings have included Medical Officer to 6th Field Ambulance and 4th/19th Prince of Wales Armoured Regiment, Senior Medical Officer 4th Brigade and Officer Commanding 6th Mobile Field Surgical Troop (6MFST). He was SO1 Health Administration in RHSA Victoria 1998-2000. He attended Reserve Staff College and Army Logistic Training Centre, and has been Chair of the General Surgery Consultative Group, Consultant in Neurosurgery to the Surgeon General and Assistant Surgeon General (Army). He was appointed Adjunct Professor to the Centre for Military and Veterans’ Health (CMVH), University of Queensland, in 2006 and is Chair of the Editorial Board of ‘ADF Health’ the journal of the Defence Health Services. He is a Board Member of the Sir Edward Weary Dunlop Medical Research Foundation and a member of the Medical Research Advisory Committee of the Defence Health Foundation. Major General Rosenfeld was awarded the Geoffrey Harkness Medal in 2001 for outstanding service to Royal Australian Army Medical Corps (RAAMC) and the Centenary Medal of Federation. He received the AM in the General List of the 2011 Queen’s Birthday Honours. He is the recipient of the Michael E DeBakey International Military Surgeons’ Award for Excellence for 2009 and was awarded a US Air Force Commendation Medal for his service in Iraq. He is one of Australia’s senior military surgeons and has served on seven operations including Rwanda, Solomon Islands, East Timor, Bougainville and Iraq. He has a particular expertise in the treatment of bomb blast injury. In his civilian work, Major General Rosenfeld is the Professor and Head of the Department of Surgery, Monash University and the Director of Neurosurgery, Alfred Hospital and is a leader in Australian neurosurgery with an international profile. He is an international leader in surgery for hypothalamic hamartoma which causes severe epilepsy in children. His particular research interest is in neurotrauma, a Principal Investigator on the Bionic Vision Project at Monash University and is leading the development of a new Institute at Monash University for Brain Development and Repair. He is Honorary Professor of Neurosurgery to the University of Papua New Guinea and Visiting Professor to the Neurosurgical Department of the Beijing Tiantan Hospital, Capital University of Medical Sciences, Beijing, China. Professor Rosenfeld has published over 220 peer reviewed articles, book chapters and a book. He is also a member of five editorial boards of international medical journals and is a member of the Ethics Committee and the Neurotrauma Committee of the World Federation of Neurosurgical Societies. He is a Paul Harris Fellow of Rotary International, was President of the United Nations Association of Australia (UNAA) Victoria and Commissioner of St John Ambulance Australia (Victoria) from December 2001 to June 2005.

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I am coming to the end of my appointment as Surgeon General Australian Defence Force-Reserves (SGADF-R) and wish to particularly thank all the Health Reservists for their service to the ADF. We continue to pass through a period of unprecedented and momentous change in the ADF with many challenges still ahead. MAJGEN Paul Alexander AO, SGADF and Commander, Joint Health (CJHLTH) has strongly led Joint Health Command through this period of change which has been made doubly challenging by the extensive savings mandated by the Strategic Reform Program (SRP). A key initiative was the move of Defence Health to VCDF Group and the formation of Joint Health Command. Health logistics has become more efficient, and Garrison Health Support has been extensively reorganized and streamlined. The E-Health system is soon to be implemented. Many other changes have been successfully implemented or are in train. A major element of Health Service provision on ADF Operations comes from the Health Reserves and this will continue. The responsibility of the SGADF-R is to lead the Health Reserves, to ensure that they are well supported, and to represent their interests within JHC and to the senior leadership of the ADF. SGADF-R helps to ensure health capability to the ADF by promoting recruitment and retention of Health Reservists particularly medical specialists. This has proved challenging at a time when the ADF is replete with personnel, with a low attrition rate but with shortages of medical officers and other health personnel. As SGADF-R, I have continued to assist CJHLTH in forging strong links between JHC and the civilian health sector, the University sector and with the Professional Colleges. We are further developing strategic alliances at Major Teaching Hospitals/Trauma Centres in each region. I have also been active in promoting the tremendous work of our Health Reservists to the wider community both here and abroad. Military frontline trauma surgery is quite different from and more challenging than civilian trauma surgery because of the greater magnitude and scope of the injuries sustained from bomb blast, the unique structure of the military trauma system and the austere environment of the forward surgical units and combat support hospitals. Although we have the excellent Definitive Surgery Trauma Course (DSTC) and a one day

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Military Module, these are arguably no longer sufficient to prepare our surgeons for war surgery. Currently, we are unable to replicate the more extensive US or British War Surgery courses. We should explore ways of further expanding our courses or securing places for our general surgeons on to the US or UK courses. A rapidly evolving evidence-based military surgical, anaesthetic and intensive care practice has emanated from the vast experience of our surgeons and our allies in Iraq and Afghanistan. We need to ensure our specialists are abreast of this information and that they can be seamlessly and confidently embedded into allied field hospitals. Even if we are not deploying our military hospital to an operation, we could embed small numbers of our personnel and individual specialists to supplement allied surgical hospitals. This has worked very well in Iraq and enables our troops to be treated by Australians and at the same time helps to deploy our superb health personnel who are highly regarded by our allies and who are keen to contribute. We also need to maintain the experience of our people in war trauma surgery and medical care but we also need to be prepared for Humanitarian Aid and Disaster Relief missions. A team of Reserve specialists able to deploy at short notice is soon to be established at the Royal Brisbane Hospital (RBH). By being embedded at the RBH, the military surgical team will remain current with trauma surgery and working as a team will be an advantage when they deploy. It should be emphasized that the ADF will still require its Specialist Reservists who are not part of these special teams to continue to staff the ongoing rotations of the future missions. Professor Michael Reade, the inaugural Professor of Military Medicine and Surgery and an active Reservist has been appointed at the University of Queensland. I wish him every success. His appointment augers well for the development of a research program in military trauma and all the national and international links and academic collaborations this will foster. The civilian disaster teams set up by each State and Territory might seem to be competing with the Reserves for members. I regard these teams as being complementary to the Reserves. Clearly, some Humanitarian Assistance missions will not require uniformed personnel. Some of our reservists will join these civilian teams and will be valued members because of their military experience. The Consultative Groups continue to provide Specialist advice to Joint Health Command on many issues of interest to

Defence. They are made up mainly of Reservists and reflect contemporary practice in the civilian and academic health sector. We need to ensure that they are well supported to do this important work. The Reserves will continue to have a regional focus and require regional support. The regional Triumvirates with leadership from the three services strongly support the Health Reserves in each region. The Triumvirates and their staff will increasingly integrate within the new regional Defence Health Structures. Although the single services manage their own health personnel there will be more tri-service integration of personnel for Garrison health support and on operations in the future. Reservists will continue to be involved in the delivery of Mental Health Services and Rehabilitation in the ADF. Reserve dentists, nurses and nurse practitioners, radiographers, physiotherapists, pharmacists, preventive medicine personnel and pathology technicians continue to make a major contribution to our overall capability and I thank them all for their service. In the future there will likely be a role for civilian paramedics to serve as Army medics. I am very proud of the Health Reservists who selflessly and repeatedly give of their time and expertise when called upon. I am particularly proud of the Reservists who help to train our deploying frontline troops in Tactical Combat Casualty Care in our Mission Rehearsal Exercises. I am sure this preparation of our Soldiers and Combat Medics is saving lives and achieving better outcomes for our injured personnel. I am also very proud of our specialists and other health professionals from the Reserves who care so diligently for our injured warriors in Afghanistan and following their return to Australia and for the support the Reserves provide to the other ADF Operations. Thank you for the superb service you all do for your single Services, the ADF and Australia. It has been an enormous privilege and honour to serve the ADF as the SGADF-R. I acknowledge the great work of my immediate predecessors, MAJGEN J Pearn AO, AVM B Short AM, and RADM G Shirtley AM, RANR. I wish my successor AVM Hugh Bartholomeusz OAM and the incoming CJHLTH, RADM Robyn Walker AM and her staff every success for their appointments and wish Joint Health Command and all Defence Health personnel well for the future. There is a strong history and foundation from which to build.

HMAS STIRLING Dental Officer, Commander Mark Brazier, conducts a routine check up on a patient with Able Seaman Dental Assistant Katrina Martin in the Fleet Base West Dental Department at HMAS Stirling.

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personal viewpoint

The inaugural Defence Chair of Military Medicine and Surgery Lieutenant Colonel Michael C. Reade MBBS, MPH, DPhil, FCCP, FANZCA, FCICM.

Lieutenant Colonel Michael Reade is Associate Professor of anaesthetics and intensive care medicine at the Austin Hospital / University of Melbourne. In late 2011 he will become the inaugural ADF Professor of Military Medicine and Surgery at the University of Queensland and the Royal Brisbane and Women’s Hospital.

The new Chair will develop trauma-related research themes building on extensive UQ infrastructure. These will initially include: • Fluid resuscitation in trauma, including effectiveness of frozen red cells and platelets in trauma resuscitation, the modulation of trauma-induced coagulopathy and inflammation, and novel methods of preserving and delivering blood clotting factors; • Characterisation and initial treatment of acute cognitive impairment associated with both critical illness and traumatic brain injury; • Pharmacological and ventilator management of traumatic lung injury sustained in blunt or blast trauma; and

Medical research related to conflict in the last ten years has led to better understandings of coagulopathy in trauma, damage control resuscitation and surgery, and the significance of mild traumatic brain injury, to name but a few. In November 2011, ADF health services take a major step into joining productive US and UK military medicine research groups with the appointment of the Defence Professor of Military Medicine and Surgery at the University of Queensland. Embedded in the UQ Burns, Trauma and Critical Care Research Centre, the major focus will be research, with additional mandates to work with the new ADF surgical team at the Royal Brisbane and Women’s Hospital, to assist training ADF procedural registrars, and to oversee deployed clinical governance. The inaugural Defence Professor of Military Medicine and Surgery is Lieutenant Colonel Michael Reade. LTCOL Reade is an intensivist and anaesthetist with a doctorate in applied molecular biology from the University of Oxford and postdoctoral research at the University of Pittsburgh focused on clinical trials. He was until recently an Associate Professor in the Department of Surgery of the University of Melbourne, and the Officer Commanding the Clinical Advisory Group of 6HSC, 3HSB. LTCOL Reade was commissioned as a General Service Officer in 1990. Transferring to the RAAMC after medical qualification, he has served extended exchange postings in the UK and US, and has deployed to Bosnia and Kosovo with the British Airborne Brigade, and East Timor, the Solomon Islands and Afghanistan with 1HSB and 3HSB. ADF Health | Vol 12 No. 1 | 2011

• Management of sepsis in trauma, including early diagnosis of sepsis and identification of infecting organisms using molecular diagnostics and investigation of methods to reduce bacterial translocation across the bowel wall; • Design of trauma systems, investigating the effectiveness of initial damage control surgery in smaller hospitals compared with longer transport times to major trauma centres. Each of these themes will benefit both civilian and military patients, and all are examples of the types of collaboration ADF clinician-investigators are invited to consider. The programme will become largely funded by extramural grants over the next 3-5 years. The clinical trials components of these programmes will make use of the world-leading Australian and New Zealand Intensive Care Society Clinical Trials Group and its affiliates. In time, it is anticipated the Chair will develop a research centre that will support ADF clinician-investigators around Australia. A new ADF Health Research Consultative Group will be formed to which suitably qualified Defence academics will be posted, with access to the laboratories and clinical trials infrastructure at the University of Queensland Centre for Clinical Research. With the possibility of conjunct academic appointments and research degrees at the University of Queensland, the new Chair’s ‘department’ will become the principal Australian centre for research of this nature.

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honours and awards

Honours and Awards

ADF Health notes with acclamation the following awards in the Australia Day Honours and the Queen’s Birthday Honours 2010/2011:

OFFICER (AO) IN THE MILITARY DIVISION OF THE ORDER OF AUSTRALIA Major General Paul Vincent ALEXANDER AO For distinguished service to Defence in the field of health and, in particular, as the inaugural Commander Joint Health Command. Major General Alexander has displayed exceptional dedication, vision and distinguished professionalism in reforming health care delivery to members of the Australian Defence Force. Over successive strategic level appointments, he has demonstrated an unwavering commitment to implement innovative solutions to health care delivery. His efforts have laid the foundation for enduring change to health care delivery and the professional development of health professionals within the Australian Defence Force.

MEMBER (AM) IN THE GENERAL DIVISION OF THE ORDER OF AUSTRALIA Major General Jeffrey Victor ROSENFELD AM For service to medicine through clinical leadership and academic roles, particularly in the field of neurosurgery as a researcher and author, and to professional associations

MEMBER (AM) IN THE MILITARY DIVISION OF THE ORDER OF AUSTRALIA

MEDAL (OAM) OF THE ORDER OF AUSTRALIA IN THE MILITARY DIVISION Lieutenant Benjamin William STOCK OAM RAN For meritorious service in the fields of Submarine Medicine and Submarine Escape and Rescue. Lieutenant Stock is an outstanding officer who has demonstrated years of commitment to the health and welfare of the members of the Submarine community in the areas of disaster management and submarine escape and rescue, as a leading figure in the progression of clinical training in the medical field, and as an advocate for veterans. His knowledge and experience in submarine medicine are unique and unrivalled in the Australian Defence Force, and his ability to think laterally has resulted in several innovations that should enhance the Royal Australian Navy’s submarine medical capability. Petty Officer Matthew Charles WOOD OAM RAN For meritorious service in health care as an Underwater Medicine Sailor in the Royal Australian Navy. Petty Officer Wood consistently performs tirelessly in the development of medical capability and health care in the Royal Australian Navy. His devotion to maintaining a capability that is flexible and responsive to high priority capability and tasking, and his commitment to self-sufficient and high readiness health care are unparalleled and have set a new benchmark in operational support. His exceptional professionalism and perseverance throughout his career embrace Navy’s core values and signature behaviours of the New Generation Navy.

Rear Admiral Graeme Spencer SHIRTLEY AM RFD RANR

CONSPICUOUS SERVICE CROSS (CSC)

For exceptional performance of duties as a medical officer in the Royal Australian Navy Reserve.

Colonel Craig Andrew SCHRAMM CSC

Rear Admiral Shirtley has provided exceptional service to the Health Services across Defence for over 40 years, culminating in his service as the Surgeon General Australian Defence Force. He has championed the work of the Naval Health Reserve and has made an outstanding contribution to the Australian Defence Force as a specialist radiologist and in the field of human research ethics.

For outstanding achievement as the Commanding Officer of the 2nd Health Support Battalion and Senior Health Officer, South Queensland. An exceptional officer displaying inspirational professional excellence as the Commanding Officer 2nd Health Support Battalion and Senior Health Officer, South Queensland, Colonel (then Lieutenant Colonel) Schramm was responsible for the provision of high readiness Level 3 combat health

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support for the Australian Army, and he ensured a very high standard of Garrison Health Support across southern Queensland. In doing so, he demonstrated outstanding achievement in the management of a complex and extensive workload. Colonel Graham Alan DURANT-LAW CSC For outstanding achievement in project management, strategic reform agenda implementation and the development and acquisition of an e-health system for Defence. Colonel Durant-Law is an exceptional officer who has throughout his career displayed extraordinary dedication to duty, the highest level of professionalism and outstanding leadership within Joint Health Command. Colonel Durant-Law has been influential in developing and implementing the Joint Health Command strategic reform program. He has shown exactitude, professionalism and dedication, particularly in leading the complex e-health agenda for Defence. Lieutenant Colonel Stephen Shaddock CSC For outstanding achievement as the Staff Officer Grade One Health Materiel Logistics and Pharmacy within Joint Health Command Flight Lieutenant Joleen Kim DARBY CSC For outstanding achievement in the application of exceptional skills as the medical officer in HMAS Childers on Thursday, 16 April 2009. Flight Lieutenant Darby’s actions were fundamental to the successful treatment of 44 injured personnel, including the survival of 27 critical and very seriously injured, following an explosion on a suspected irregular entry vessel near Ashmore Reef. Her compassion, professionalism, outstanding leadership and exceptional skills in coordinating triage, administering medical treatment, advising others how to address medical concerns, and monitoring the casualties for 12 hours in the most basic conditions ensured their pain and suffering were minimised. The injured personnel were delivered to expert medical care in the best possible condition, and they survived their trauma.

to ensure better health outcomes for service personnel and, consequently, enhance the Royal Australian Air Force’s personnel capability. Her superior analytical skills, outstanding practical expertise and tireless devotion to duty have ensured equitable and expedient treatment of Air Force Reserve members in the often highly emotive and sensitive area of service members’ health. Chief of the Defence Force Gold Commendation Corporal Sharon Louise Jager I commend you for your exceptional dedication and outstanding competency in treating casualties on board HMAS CHILDERS, HMAS ALBANY and platform FRONT PUFFIN following an explosion on Suspected Irregular Entry Vessel 36 near Ashmore Reef on 16 April 2009.You were on the suspected irregular entry vessel when it exploded but despite your injuries you worked tirelessly, in extremely difficult conditions, to administer life saving treatment to dozens of casualties, including many critical or very seriously ill patients. Your dedication and tireless efforts, and your succinct and accurate medical information and direction, inspired and enabled others to provide the highest quality of care possible to the injured. Your professionalism and personal courage, combined with your calm demeanour, pragmatism, initiative and inspirtional leadership were fundamental to the survival of the casualties in your care. Your achievements are of the highest order and in keeping with the finest traditions of the Royal Australian Air Force and the Australian Defence Force.

SENIOR PROMOTIONS ADF Health congratulates the following senior health officers on their promotions: RADM Robyn Margaret Walker AM RAN: to Joint Health Commander with efffect December 2011 AVM Frederick Hugh Bartholomeusz OAM RFD: to Surgeon General Defence Health Reserves with efffect December 2011

Captain Andrew Peter CHALLEN CSC For outstanding achievement as the Regimental Medical Officer of 1st Battalion, the Royal Australian Regiment. Captain Challen’s vision, dedication and tireless pursuit of excellence have made an outstanding contribution to the management of battlefield trauma, training of medics, and psychological preparation of soldiers for operations, and have directly saved the lives of Australian soldiers from combat wounds. His outstanding achievements as a Regimental Medical Officer are in the finest traditions of the Australian Army and the Australian Defence Force.

CONSPICUOUS SERVICE MEDAL (CSM) Flight Sergeant Jenny Leigh DILLON, CSM For meritorious achievement as the Medical Support and Policy Subject Matter Expert within the Directorate of Personnel – Air Force.

Personnel prepare for the long flight on board the C-17 Globemaster at RAAF Base Amberley shortly before leaving for Pakistan. AusAID and ADF specialist medical and engineering personnel as well as aid and emergency stores are to deploy via C-17 to provide emergency medical and health support to the victims of the Pakistan floods.

Flight Sergeant Dillon’s diligence, initiative and professional excellence have seen her positively influence health policy ADF Health | Vol 12 No. 1 | 2011

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review article

Review of fluid resuscitation and massive transfusion protocols from a military perspective Captain Thileepan Naren, Colonel Alistair Royse and Lieutenant Colonel Michael C. Reade

Captain Thileepan Naren MB BS RAAMC CAPT Thileepan Naren joined the Army Reserves in 2008 and was posted as a Medical Officer to 3HSB-6 Health Support Company. In civilian practice he is a resident medical officer at Box Hill Hospital. He has interests in both general practice and emergency medicine.

Colonel Alistair Royse MBBS MD FRACS FCSANZ Colonel Royse joined the Army in 1980 and has previously been posted to infantry or special forces battalions and served as SMO 4 Brigade. He is currently a member of the Specialist Advisory Group of 3HSB. He is a cardiothoracic surgeon. He is a professor at the University of Melbourne, and the co-director of the Ultrasound Education Group at Melbourne University and is involved in cardiovascular research.

Lieutenant Colonel Michael Reade MBBS BSc DPhil(Oxon) MPH DIMCRCSEd DMCC FCCP FANZCA FCICM Lieutenant Colonel Michael Reade is Associate Professor of anaesthetics and intensive care medicine at the Austin Hospital / University of Melbourne. Commissioned as a GSO in 1990, he transferred to the RAAMC after medical qualification and served on exchange with 144 Parachute Medical Squadron in London and the 2nd Armoured Division in Texas. He deployed with the British Army 16 Air Assault Brigade to Bosnia in 2000 and Kosovo in 2001, and with 1HSB to East Timor in 2003 and the Solomon Islands in 2004. In 2009 he was the clinical director of the NATO Role 2(E) Hospital, Tarin Kot, Afghanistan. He is the OC of the Specialist Advisory Group of 6HSC-3HSB. In late 2011 he will become the inaugural ADF Professor of Military Medicine and Surgery at the University of Queensland and the Royal Brisbane and Women’s Hospital. Correspondence: thileepan.naren@gmail.com

Abstract The approach to resuscitation of wounded patients with major haemorrhage has changed dramatically in the last ten years, in part due to recent military experience. The United States military has formulated ‘Tactical Combat Casualty Care’ guidelines for pre- and early- hospital management, adapting clinical evidence to the military environment. With the exception of fluid management advice, these guidelines are equally applicable to the Australian Defence Force. Emphasis on rapid control of bleeding, with surgery forming part of resuscitation rather than an activity that follows attempts at stabilisation, while sound, challenges traditional clinical and organisational teaching. However, the indications, type, route of administration and endpoints of fluid resuscitation, particularly in the early hospital period, warrant further examination. This review of available evidence makes recommendations in these areas as a stimulus for debate, and ultimately policy development, within the Australian Defence Force.

Introduction The primary treatment of major haemorrhage is to stop the bleeding. Useful measures include arterial tourniquets, pressure dressings with or without impregnated haemostatic agents, and early damage control surgery. No study has ever found that pre-hospital time spent administering fluid to patients with major haemorrhage is of any benefit. On the contrary, studies convincingly demonstrate either no benefit 1 or harm. 2;3 Moreover, analysis of timing of deaths and vital signs on admission to hospital suggests that fluid resuscitation of any sort might only benefit less than 2% of wounded patients.1;4 Therefore, while there is extensive debate over fluid resuscitation in military trauma, this minimally relevant to the vast majority of patients. Nonetheless, recommendations on fluid resuscitation are frequently sought, and it is incumbent on military physicians to provide the best advice possible. In this review, we assess current evidence guiding four essential questions (optimal indications, route of administration, type of fluid, and endpoints) related to fluid resuscitation in military

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trauma, along with incorporation of fluid resuscitation into the overarching ‘damage control resuscitation’ concept. We also analyse the recommendations of the US Tactical Combat Casualty Care (TCCC) programme, which provides guidance on these matters for the US military. Our analysis states neither current Australian Defence Force (ADF) policy nor the consensus of Defence Health practitioners, but is presented to stimulate debate to better inform the care of wounded ADF members.

volume in major haemorrhage is therefore not required. Furthermore, attempts to do this appear harmful. Replacing each litre of blood lost with three litres of crystalloid makes sense from the relative sizes of the intra- and extravascular fluid compartments,(8) but leads to substantial dilution of the blood constituents, fluid overload with interstitial oedema and the acute respiratory distress syndrome, or ‘Da Nang Lung’ (named after the town in which many US and allied casualties received treatment during the Vietnam war).(4)

Tactical Combat Casualty Care

The concept of providing the least possible fluid resuscitation to preserve perfusion to heart, lung and brain has become known as ‘hypotensive resuscitation’, as blood pressure measurement is easier than measuring flow to those organs. The benefit of hypotensive resuscitation was first convincingly demonstrated by Bickell et al.(2) in a quasi-randomised controlled trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries. Hospital survival was higher in the delayed resuscitation group (70% vs 62% p=0.04). Patients in the immediate resuscitation group had longer total hospital stays, and there was a non-significant trend towards more complications. The explanation for the differences observed was not empirically explored, but the authors and others hypothesised that restoration of a more ‘normal’ blood pressure dislodges any clot that may have formed and dilutes coagulation factors, precipitating further haemorrhage.(4) Supporting this, a trend towards more intraoperative blood loss was observed in the immediate resuscitation group. This study brought hypotensive resuscitation into mainstream medical practice.

The United States military developed the Tactical Combat Casualty Care (TCCC) project to guide battlefield trauma care in 1996, with many revisions of the original guidelines.(5;6) The essence of TCCC is to recognise appropriate trauma care on the battlefield is shaped by the tactical environment. The principles of TCCC are completion of the mission, prevention of further casualties, and lastly the treatment of the casualty. With respect to major haemorrhage, the initial goal of TCCC treatment is to obtain haemostasis. A second critical concept is that prior to definitive control of the haemorrhage, any elevation of the blood pressure leads to more rapid bleeding and exsanguination. Fluid resuscitation is only recommended for a systolic blood pressure of <80-85 mmHg, a falling blood pressure, or reduced consciousness without evidence of head injury.(4) In practice, this is simplified to only giving fluid resuscitation if the patient is unconscious or does not have a palpable radial pulse. Hetastarch 6% in a balanced salt solution (Hextend; Hospira Pty Ltd, Lake Forest IL, USA), not available in Australia, is the recommended resuscitation fluid for prehospital care. Hetastarch is a carbohydrate molecule into which hydroxyethyl groups have been substituted for some of the glucose molecules. It is distinguished from other substituted starches used for fluid resuscitation, such as Pentastarch, by its average molecular weight and the degree of molar substitution. Hextend is given as a 500ml bolus, repeated once if indicated by level of consciousness or absence of a radial pulse. An intraosseous needle is recommended if an 18 gauge intravenous cannula is not easily inserted. Hypothermia is prevented using a chemical heating blanket and a heat reflective shell. Early evacuation from the battlefield and early damage control surgery is prioritised. TCCC reflects evidence for limited, if any, prehospital fluid administration, and expert opinion on the demands of the prehospital tactical environment. With the exception of choice of fluid, discussed below, we assess the guidelines a synthesis of current best practice in prehospital haemorrhage control and fluid resuscitation.

Indications for fluid resuscitation The goal of fluid resuscitation is to allow sufficient circulating blood volume to deliver oxygen and energy substrates to the cells essential to life, and to remove their products of metabolism. Mechanisms exist to divert circulating blood volume to cells that need it most. For example, renal perfusion is reduced as cardiac output falls, but renal cells suffer little in this process, with less than 1% of trauma patients requiring renal replacement, mostly as a component of late multi-organ failure.(7) Early restoration of a normal circulating blood

The study by Bickell at al.(2) is open to a number of criticisms. An alternate day selection method rather than true randomisation was used. This introduced a risk of unmeasured confounding variables – such as one surgical team tending to look after one group more than the other. The authors argued that alternate day allocation was required to avoid delays in initiation of therapy. It is unclear whether the results can be extrapolated to include blunt trauma or pressure injuries from blast. Penetrating trauma is more likely to involve large vessels, in which higher pressure might cause ongoing bleeding, whereas capillary bleeding in blunt trauma may be less affected. Jackson et al.(9) reviewed hypotensive resuscitation in three groups: penetrating, blunt and head injury. This review included animal as well as human studies, finding the Bickell study(2) the only human study from which conclusions could be drawn. Animal studies consistently showed that excessive crystalloid resuscitation increases the circulating volume and systolic blood pressure, but also increases or restarts bleeding. The evidence supporting hypotensive resuscitation in blunt trauma and head injury is very limited. Thus there is physiological theory (regarding clot disruption and dilutional coagulopathy), evidence from these animal studies, but only one large clinical trial supporting this approach. In the hospital environment, with access to tests of coagulation, lactate, and cardiac output monitoring, the appropriate threshold for fluid resuscitation in trauma patients has never been adequately studied. Recommendation: Surgical control of bleeding should not be delayed to allow fluid resuscitation.

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Route of fluid administration Rapid circulatory access in trauma cases may be required for fluid resuscitation, analgesia, antibiotics and induction of anaesthesia. Despite the arguments listed in favour of limited fluid resuscitation prior to haemorrhage control, the Early Management of Severe Trauma course (derived from the Advanced Trauma Life Support course(10)) recommends the insertion of large-bore parenteral access devices to allow rapid fluid administration. As discussed, this approach is likely to be more valuable after haemorrhage is controlled. Peripheral cannulation is frequently difficult in hypovolaemic shock due to peripheral venous shutdown. Limbs injured by combat wounds , combined with environmental and tactical conditions, may make traditional forearm sites for peripheral venous cannulation unsuitable. Similarly, large 14 gauge cannulae may be impossible to insert. TCCC recognises this, recommending instead 18 gauge cannulae as a compromise between maximal flow rates and ease of insertion. Once in hospital, better options for large bore intravenous access may be available. A conventional triple-lumen central venous catheter usually has one 16 gauge and two 18 gauge lumens, but the flow that can be achieved is substantially limited by the extra resistance imposed by the 15-20 cm length. The typical internal diameter of a pulmonary artery catheter sheath (figure 1) is 8.5 French, or 2.8mm, which allows flows of 400-800ml/min. An even better option is a temporary dialysis catheter (figure 2), which has two lumens of typically 13.5 French (4.5mm) each. Less likely to kink, flow rates in excess of 1L/min can be achieved without excessive driving pressures. Central venous access can, however, take time and skill. A better immediate approach is the intraosseous (IO) route (figure 3). Leidel et al.(11) compared success rates and procedure times of IO vs. central venous catheter (CVC) access in adult patients undergoing fluid resuscitation. Success rate on first attempt was 90% for IO versus 60% for CVC insertion, with less time required to obtain IO access (2.3 Âą 0.8 min vs. 9.9 min Âą 3.7). The IO route is effective in the military environment. Cooper et al.(12) reported a military case series of 16 adults and 10 children in whom 97% of IO needles, including those inserted in-flight (helicopter), functioned effectively. Flow rates through intraosseous needles are determined by the insertion site and whether or not a pressure bag is used. Flows range from 68 to 204 ml/min in the tibial position, (not driven and driven by a pressure bag) and 82-148 ml/min in the humerus,(13) both of which are substantially inferior to that through largebore central venous access. However, all drugs given IV can be given IO,(14) and it is possible to crossmatch blood and to obtain samples for standard laboratory investigations through the IO route.(15) The technique appears to be safe with few complications if aseptic conditions can be maintained and prolonged infusion times and multiple insertion attempts into the same bone are avoided. The largest case series (of 4270 cases) reported an incidence of osteomyelitis of 0.6%.(16) Therefore, the greatest utility of IO access is in situations when peripheral IV access is impossible, to facilitate administration of drugs and the minimal volumes of fluid recommended prior to control of bleeding, as a bridge to a large volume infusion line. Recommendation: Emergency prehospital vascular access may be readily achieved by an intraosseous needle when an

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intravenous cannula is not possible, if intravenous fluid therapy is indicated. In hospital, large bore central venous access lines should be available and considered for use.

Figure 1 Pulmonary artery catheter sheath. 8.5 French allows flow rates of 400-800 ml/min.

Figure 2 Temporary haemodialysis catheter (Vas-Cath). Two 13.5 French lumens each allow flow rates of >500 ml/min

Figure 3 The EZ-IO intraosseous needle insertion device. The 15 gauge needle allows flows of up to 200 ml/min, depending on location

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Type of resuscitation fluid No intravenous fluid used for the resuscitation of patients in haemorrhagic shock has ever been found to produce superior patient-centred outcomes when compared to any other fluid. Each of the available alternatives has at least one theoretical and laboratory end-point argument favouring its use. The US TCCC recommendation for Hextend is based primarily on the lower weight of a bag of fluid (compared to crystalloid) required to produce a haemodynamic effect, at least in the short term.(4) However, Hextend is not licensed by the Therapeutic Goods Administration for use in Australia, which leaves Australian military doctors the task of assessing the available evidence themselves. Crystalloid solutions have historically been the resuscitation fluid of choice in US, in contrast to the colloids used in the Europe. Despite the recommendations of TCCC, half of US military prehospital medics prefer to use crystalloids for this indication.(4)

Crystalloids Large volumes of 0.9% (‘normal’) saline produce a hyperchloraemic metabolic acidosis, as noted by Schreiber(17) in his recent review. This may be associated with systemic vasodilation, increased extravascular lung water, and coagulopathy. The most commonly used alternatives, Hartmann’s or lactated Ringer’s solutions, replace some of the chloride of 0.9% saline with lactate. In the setting of large volume resuscitation of haemorrhagic shock, this can result in transiently increased lactate levels that are not associated with acidosis. Lactate is rapidly converted to bicarbonate by a functioning liver. If hepatic function is impaired, Plasma-Lyte 148 (Baxter, NSW, Australia), which contains gluconate and acetate rather than lactate, may avoid this problem. Mahler et al.(18) performed a double blinded randomised controlled trial comparing metabolic acidosis in the resuscitation of 52 patients with diabetic ketoacidosis with either normal saline or Plasma-Lyte. Resuscitation with PlasmaLyte resulted in lower serum chloride and higher bicarbonate levels. McFarlane et al.(19) found similar results in patients following hepatobiliary and pancreatic surgery. However, it may be unwise to extrapolate biochemical effects to outcome benefit. Rizoli(20) concluded that there was no evidence that Plasma-Lyte is superior to other crystalloids for the prehospital management of traumatic hypovolaemia. On balance, if a single resuscitation crystalloid must be chosen, Hartmann’s or Plasma-Lyte seem better choices than 0.9% saline. However, a military hospital with access to even basic biochemical testing should ideally have the ability to tailor the electrolyte composition of resuscitation fluids to a patient’s needs. Recommendation: Plasma-Lyte (higher cost) or Hartmann’s solution (lower cost) should be used for immediate fluid resuscitation if a crystalloid is chosen. Other fluids should be available for use in hospital, guided by biochemical analysis.

Colloids In Australian practice, the choice of colloid is between Haemaccel (polygeline)(AFT Pharmaceuticals, NSW), Gelofusine (B.Braun, NSW), Albumin (CSL Bioplasma, VIC), and Voluven (hydroxyethyl starch) (Fresenius Kabi, NSW). Notably, while both Hextend and Voluven are hydrxyethyl

starches, their molecular structures are different, which may lead to different adverse effect profiles. Ogilvie et al.(21) examined the safety and efficacy of Hextend at a Level I trauma centre, with particular focus on the risk of coagulopathy. Over a six month period Hextend was made available for all non-burn patients. At the discretion of the admitting surgeon, 500-1,000 mL of Hextend was administered during initial fluid resuscitation. Initial resuscitation with Hextend was associated with reduced mortality and no obvious coagulopathy. This was the first trial of Hextend in haemodynamically unstable trauma patients and the largest trial to date in any population of surgical patients, but the impact of the findings is diminished because the treatments were not randomised or blinded. Allison et al.(22) studied 45 patients with blunt abdominal trauma randomised to receive either hydroxyethyl starch (Pentaspan, not available in Australia) or Gelofusine in the first 24 hours following hospital admission. Patients in the hydroxyethyl starch group showed fewer instances of posttraumatic capillary leak. There is therefore limited evidence to show that hydroxyethyl starches may be safe and may cause less peripheral oedema than Gelofusine (and by extrapolation, Haemaccel). A recent review by Ogilvie et al.(23) recommended that a randomised, blinded, and adequately powered trial, especially in severely injured penetrating trauma patients, is necessary before these data can be accepted with confidence. The main risk of gelatins is anaphylaxis, and of starches is renal impairment. A database study of nearly 20 000 patients found the risk of anaphylaxis was 6 times higher for gelatins compared to starch.(24) However, a systematic review of 34 studies involving 2607 patients by Dart et al.(25) found a relative risk of 1.5 for acute kidney injury in patients who had received hydroxyethyl starch when compared with other fluid therapies. There was a relative risk of 1.38 requiring renal replacement therapy. Limited recent studies report third-generation hydroxyethyl starches are safer,(26) but this question is currently the subject of an 8000-patient randomised controlled trial of Voluven vs. 0.9% saline in Australia and New Zealand (the Crystalloid versus HydroxyEthyl Starch (CHEST) study(27)). Recommendations with respect to Voluven, and starches in general, made prior to the results of this trial would be premature. Recommendation: There is currently insufficient evidence to recommend one colloid over another.

Crystalloids vs. Colloids The Australasian 6997-patient Saline versus Albumin Fluid Evaluation (SAFE) Study(28) found no difference in 28 day mortality in ICU patients requiring fluid resuscitation randomised to receive either 4% albumin or normal saline. On subgroup analysis there was a strong trend towards increased mortality in the subset of trauma patients with traumatic brain injury receiving albumin,(29) which the authors hypothesised might have been due to exacerbation of vasogenic or cytotoxic cerebral oedema. The SAFE study is the largest ever comparison of crystalloids and colloids for fluid resuscitation. However, only a minority of patients were in haemorrhagic shock at the time of this infusion. Additionally, the findings may be specific to albumin and not extrapolate to gelatins or starches. A Cochrane review(30) of 63 eligible

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trials concluded there was no evidence that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids. Similarly, a review by Grocott et al.(31) of the available clinical outcome data found no evidence for relative advantage of crystalloid and colloid fluid therapy, or between the different types of colloid. The lack of clear evidence demonstrating superiority of crystalloids or colloids leads to a number of conclusions. First, that if there is a difference in outcome, it is unlikely to be large when the therapy is applied to a heterogeneous population. Whether a more targeted approach would allow better outcomes with particular therapies in particular patients remains in question. Second, if logistical considerations are paramount, the possible requirement for less fluid for a similar haemodynamic effect (based both on physiological understanding and also the results of the SAFE study) suggest colloids may be the better choice. However, the logistical concerns around the extra weight of crystalloid may be overstated, as reflected by the continued use of crystalloid by US medics despite TCCC recommendations.(4) Recommendation: Colloids should not be used for fluid resuscitation unless minimisation of weight carried is an overriding consideration. The weight advantage of colloids is probably overstated.

Hypertonic solutions Hypertonic solutions theoretically have a greater ability (per volume infused) to expand blood volume, by recruiting

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extracellular fluid into the circulation. Smaller volumes should be required over shorter time periods. The ability to achieve the same effect with less fluid led the US TCCC committee to recommend a 250ml bolus of 7.5% hypertonic saline (in addition to 500ml of Hextend), essentially for reasons of speed and logistics. However, the recommendation was not adopted,(4) at least in part because this fluid was not commercially available in the United States.(32) The effectiveness of hypertonic solutions was explored by Bunn et al.(33) in their review of 14 trials involving 956 participants. Clinical heterogeneity made a pooled meta-analysis inappropriate. However, studies identified in this systematic review did not clearly demonstrate any outcome advantage with hypertonic crystalloid. Hypertonic saline was thought to hold particular advantage for patients with traumatic brain injury, with the hypothesis that brain oedema might be lessened. The definitive study of this concept was performed in 229 patients Melbourne,(34) which found no improvement in neurological function detected at the six month follow up period when compared with conventional fluid resuscitation. Recommendation: Hypertonic solutions should not be used for fluid resuscitation.

Oxygen-carrying blood substitutes and other experimental fluids A blood substitute is a synthetic solution that carries oxygen and include substances based on haemoglobin (surface-modified haemoglobin, intramolecular cross-linked haemoglobin and

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polymerised haemoglobin) or perfluorocarbon. There is mixed data on the efficacy and safety of these substitutes. (36;36) Australian experience is limited to case reports, such as that of a Jehovah’s Witness requiring transfusion but refusing blood products.(37) ‘Pharmacological’ resuscitative fluids designed to protect and reduce ischemia-reperfusion are currently being developed. Pyruvate, Na+/H+ exchange (NHE) inhibitors, valproic acid, dihydroepiandrosterone (DHEA)(38) and adenosine/lignocaine/hypertonic saline(39) are amongst in the novel agents currently under investigation. However all of these experimental approaches are not licensed for use in Australia and as such beyond the scope of this review.

patient outcomes.(45) For example, in a cohort of 1813 trauma patients, of patients who received at least six units of packed red cells, the duration for which units had been stored was an independent predictor of higher mortality.(46) The mechanism for this may be lower 2,3 DPG levels, reduced nitric oxide production, increased cell rigidity, transfer of oxygen from recipient to donor red cells,(47) or some other yet to be appreciated factor. However, in the absence of randomised controlled trial evidence, it is not possible to be certain of this hypothesis. The effect of age of transfused red cells is currently the subject of a research programme of the Australian and New Zealand Intensive Care Society Clinical Trials Group.

Recommendation: Blood substitute solutions should not be used outside of experimental protocols

Recommendation: Patients with massive haemorrhage (expected to require more than 10 units of packed red cells) should receive minimal non-blood resuscitation and early red cells, plasma and platelets (or whole blood) as part of a damage control resuscitation strategy (see below). Non-blood fluid should only be given to maintain consciousness or a palpable radial pulse, as in the TCCC recommendations. Where the likely degree of haemorrhage is less obvious the merits of blood vs. non-blood transfusion are at present less clear. The best strategy may be a combination of titration to laboratory values combined with a bias to early use of blood components in response to ongoing bleeding.

Blood products The most appropriate resuscitation fluid for massive blood loss is whole blood. This simple and obvious statement was appreciated in the 1960s,(4) when there were few alternatives, but fell from popularity when blood suppliers began to separate blood into components in an effort to maximise the use of a limited supply. Until recently, conventional teaching was to give 4 litres of non-blood product resuscitation before considering red cell transfusion,(40) and only after coagulopathy was objectively demonstrated to consider replacement of coagulation factors and platelets.(41) Not surprisingly, this resulted in marked coagulopathy that was difficult to reverse. Fluid resuscitation in major haemorrhage was revolutionised after the publication of an observational study from a US combat hospital in Iraq.(42) This retrospective cohort study identified 246 patients who had received a massive transfusion (≥10 units of red cells in 24 hours). Participants were placed into three groups based on the ratio of plasma to packed red blood cells that they had received: low ratio (1:8 ratio of plasma to packed red blood cells); medium ratio (1:2.5) and high ratio (1:1.4). The higher ratio patients had a significantly lower mortality (65%, 34%, and 19% for low, medium and high ratio groups (p < 0.001)) and this effect persisted after adjustment for relevant confounders. Death occurred sooner in the low and medium ratio groups than in the higher ratio group (2,4 and 38 hours respectively). However, as with all observational studies, associations are not proof of causality. The larger number of deaths in the low ratio groups might be due to them receiving less plasma. However, another possible explanation is that, by dying earlier, patients were less likely to have had time to receive plasma. Nonetheless, the findings have been replicated in a study of 467 patients in 16 US civilian trauma centres(43) and in 2746 patients in a single US trauma centre.(44) Given the strength of the association, its replication in other settings, and its biological plausibility, it is now likely there would be insufficient equipoise to perform a randomised controlled trial. The challenge is therefore to identify early patients who will require a massive transfusion, and commence high-ratio plasma (and platelet): packed red cell resuscitation as soon as possible. Minimal volumes of nonblood fluids administered prior to hospital, as recommended in TCCC, facilitate this strategy. On the basis of observational cohort studies, the age of packed red cells has recently been suggested to influence

Resuscitation endpoints As with all pharmacological interventions, achieving the correct ‘dose’ of fluid resuscitation is likely to be just as important as selecting the optimal resuscitation fluid. This concept is increasingly recognised in elective surgery. For example, Nisanevich et al.(48) compared patients undergoing elective abdominal surgery randomly assigned to receive either liberal (bolus of 10 ml/kg followed by 12 ml/kg/hr) or restrictive (4 ml/kg/hr) volumes of fluid. Complications were fewer in the restrictive group (p= 0.046). Patients in the liberal group has a later return of bowel function, and their postoperative hospital stay was longer. Systematic review of similar studies has been limited by highly variable definitions of ‘restrictive’ and ‘liberal’ fluid resuscitation strategies,(49) and the question has not yet been subjected to meta-regression analysis. There have been no equivalent studies in trauma patients, who commonly having had a substantial period of pre-resuscitation hypoperfusion, may or may not respond differently to elective surgery patients. Rather than approach ‘resuscitation dose’ as a one-size-fits-all question, trauma resuscitation in particular may benefit from fluid volumes tailored to physiological derangements of individual patients. Resuscitation performed in hospital does not have to rely on blood pressure alone as a surrogate for adequacy of the circulation. Eighty-five percent of severely injured patients still have a metabolic acidosis after their blood pressure is normalised. (50) Arterial lactate(50) and urine output are better indices of organ perfusion. Gan et al.(51) studied goal directed fluid management in 100 patients who were to undergo major elective surgery. Patients were randomly assigned to standard care or intraoperative plasma volume expansion guided by cardiac output (measured by oesophageal Doppler), with the goal of maintaining maximal stroke volume. Goal-directed intraoperative fluid administration resulted in earlier return to bowel function, lower incidence of postoperative nausea and vomiting, and decrease in length of postoperative hospital stay. Similarly,

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thromboelastography (TEG) has been advocated to allow goaldirected management of coagulopathy in trauma patients.(52) Near infra-red spectroscopy measurement of tissue oxygen saturation is a feasible and theoretically attractive measure of tissue perfusion(53) that clearly identifies patients in severe traumatic shock,(54) but is yet to be subjected to a randomised controlled trial with patient-centred outcomes. Similar promise, awaiting definitive evidence, is held for buccal capnometry,(55) sublingual capillary sidestream dark field imaging(56) and muscle oxygen measurement.(57) Theoretically the most appeal­ing approach is direct imaging of inferior vena cava dia­ meter, myocardial filling and contractility using transthoracic or transoesophageal echocardiography.(58-60) Many of the moni­ tors required to assess these resuscitation endpoints are robust, simple to use, and so amenable to deployment in military hospitals.

Damage Control Surgery and Resuscitation Discussion of modern fluid resuscitation would be incomplete without mention of damage control resuscitation and surgery. Damage control resuscitation emphasises that surgery forms part of resuscitation, rather than existing as a separate event after the patient is ‘resuscitated’. An exsanguinating patient is taken directly to an operating theatre, where monitors are inserted and fluid resuscitation commenced at the same time as the surgical team stops the bleeding. This approach challenges both traditional clinical and organisational thinking. Clinicians were traditionally taught a patient had to be ‘resuscitated’ before proceeding to the operating theatre. Health planners, particularly in the military, designed systems that took patients to small, non-surgical ‘resuscitation’ facilities for stabilisation prior to movement to a surgical hospital. Recommendation: The concept of non-surgical resuscitation of major trauma is outdated and should be abandoned by clinicians and planners alike.

Summary and recommendations On the basis of the evidence presented, for the fluid resuscitation of ADF trauma patients we recommend: 1. Battlefield strategy. The principles of Tactical Combat Casualty Care, including emphasis on haemorrhage control and rapid evacuation for operative management of haemorrhage, are valid. The recommendation for Hextend is currently not appropriate in the Australian context. Hartmann’s solution or Plasma-Lyte should be given in 500ml aliquots solely to maintain palpable radial pulse and mentation.

Conflict of interest statement Captain Naren and Colonel Royse declare that they have no competing interests in relation to the material in this paper. Lieutenant Colonel Reade is an investigator in the Australian and New Zealand Intensive Care Society Clinical Trials Group trial of Voluven vs. saline (CHEST), but has received no personal or grant support from Fresenius Kabi, the manufacturer of Voluven.

Reference List (1) Kaweski SM, Sise MJ, Virgilio RW. The effect of prehospital fluids on survival in trauma patients. J Trauma 1990; 30(10):1215-1218. (2) Bickell WH, Wall MJ, Jr., Pepe PE, Martin RR, Ginger VF, Allen MK et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994; 331(17):1105-1109. (3) Cotton BA, Guy JS, Morris JA, Jr., Abumrad NN. The cellular, metabolic, and systemic consequences of aggressive fluid resuscitation strategies. Shock 2006; 26(2):115-121. (4) McSwain NE, Champion HR, Fabian TC, Hoyt DB, Wade CE, Eastridge BJ et al. State of the Art of Fluid Resuscitation 2010: prehospital and Immediate Transition to the Hospital. Journal of Trauma 2011; 70(5):S2-S10. (5) Butler FK. Tactical Combat Casualty Care: update 2009. J Trauma 2010; 69 Suppl 1:S10-S13. (6) Butler FK, Jr., Holcomb JB, Giebner SD, McSwain NE, Bagian J. Tactical combat casualty care 2007: evolving concepts and battlefield experience. Mil Med 2007; 172(11 Suppl):1-19. (7) Morris JA, Jr., Mucha P, Jr., Ross SE, Moore BF, Hoyt DB, Gentilello L et al. Acute posttraumatic renal failure: a multicenter perspective. J Trauma 1991; 31(12):1584-1590. (8) Shires GT, Carrico CJ, Coln D. The Role Of The Extracellular Fluid In Shock. Int Anesthesiol Clin 1964; 2:435-454. (9) Jackson K, Nolan J. The role of hypotensive resuscitation in the management of trauma. Journal of the Intensive Care Society 2009; 10(2):109-114. (10) ATLS ® for Doctors Student Manual. 8 ed. Chicago, IL: American College of Surgeons; 2008. (11) Leidel BA, Kirchhoff C, Bogner V, Stegmaier J, Mutschler W, Kanz KG et al. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Saf Surg 2009; 3(1):24. (12) Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A. Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience. J R Army Med Corps 2007; 153(4):314-316. (13) Ngo AS, Oh JJ, Chen Y, Yong D, Ong ME. Intraosseous vascular access in adults using the EZ-IO in an emergency department. Int J Emerg Med 2009; 2(3):155-160. (14) Dubick MA, Holcomb JB. A review of intraosseous vascular access: current status and military application. Mil Med 2000; 165(7):552-559.

2. Hospital resuscitation strategy. Damage control surgery should be performed without delay. A high ratio of plasma with packed red blood cells should be used in the initial resuscitation of patients with anticipated massive (≥10 units) haemorrhage. Where crystalloid resuscitation is required, Plasma-Lyte or Hartmann’s solution are most likely to be appropriate.

(15) Orlowski JP. Emergency alternatives to intravenous access. Intraosseous, intratracheal, sublingual, and other-site drug administration. Pediatr Clin North Am 1994; 41(6):1183-1199.

3. Operative and postoperative fluid management. Goal directed fluid management should be used when possible, including measurement of clinical (such as urine output), biochemical (such as lactate) and haemodynamic (such as cardiac output) indices.

(18) Mahler SA, Conrad SA, Wang H, Arnold TC. Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis. Am J Emerg Med 2011; 29(6):670-674.

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(16) Rosetti VA, Thompson BM, Miller J, Mateer JR, Aprahamian C. Intraosseous infusion: an alternative route of pediatric intravascular access. Ann Emerg Med 1985; 14(9):885-888. (17) Schreiber M.A. The use of normal saline for resuscitation in trauma. Journal of Trauma-Injury Infection and Critical Care 2011; 70(5):S13-S14.

(19) McFarlane C, Lee A. A comparison of Plasmalyte 148 and 0.9% saline for intra-operative fluid replacement. Anaesthesia 1994; 49(9):779-781.

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(20) Rizoli S. PlasmaLyte. Journal of Trauma-Injury Infection and Critical Care 2011; 70(5):S17-S18. (21) Ogilvie MP, Pereira BM, McKenney MG, McMahon PJ, Manning RJ, Namias N et al. First report on safety and efficacy of hetastarch solution for initial fluid resuscitation at a level 1 trauma center. J Am Coll Surg 2010; 210(5):870-872. (22) Allison KP, Gosling P, Jones S, Pallister I, Porter KM. Randomized trial of hydroxyethyl starch versus gelatine for trauma resuscitation. J Trauma 1999; 47(6):1114-1121. (23) Ogilvie MP, Ryan ML, Proctor KG. Hetastarch during initial resuscitation from trauma. Journal of Trauma-Injury Infection & Critical Care 2011; 70(5):S19-S21. (24) Laxenaire MC, Charpentier C, Feldman L. [Anaphylactoid reactions to colloid plasma substitutes: incidence, risk factors, mechanisms. A French multicenter prospective study]. Ann Fr Anesth Reanim 1994; 13(3):301-310. (25) Dart AB, Mutter TC, Ruth CA, Taback SP. Hydroxyethyl starch (HES) versus other fluid therapies: effects on kidney function. Cochrane Database of Systematic Reviews 2004; 3(CD002045). (26) Godet G, Lehot JJ, Janvier G, Steib A, De C, V, Coriat P. Safety of HES 130/0.4 (Voluven(R)) in patients with preoperative renal dysfunction undergoing abdominal aortic surgery: a prospective, randomized, controlled, parallel-group multicentre trial. Eur J Anaesthesiol 2008; 25(12):986-994. (27) The Crystalloid versus Hydroxyethyl Starch Trial: protocol for a multi-centre randomised controlled trial of fluid resuscitation with 6% hydroxyethyl starch (130/0.4) compared to 0.9% sodium chloride (saline) in intensive care patients on mortality. Intensive Care Med 2011; 37(5):816-823. (28) Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350(22):2247-2256. (29) Myburgh J, Cooper DJ, Finfer S, Bellomo R, Norton R, Bishop N et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med 2007; 357(9):874-884. (30) Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2011;(3):CD000567. (31) Grocott MP, Mythen MG, Gan TJ. Perioperative fluid management and clinical outcomes in adults. Anesth Analg 2005; 100(4):1093-1106. (32) Ling GS, Rhee P, Ecklund JM. Surgical innovations arising from the Iraq and Afghanistan wars. Annu Rev Med 2010; 61:457-468. (33) Bunn F, Roberts I, Tasker R, Akpa E. Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2004;(3):CD002045. (34) Cooper DJ, Myles PS, McDermott FT, Murray LJ, Laidlaw J, Cooper G et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA 2004; 291(11):1350-1357. (35) Moore EE, Moore FA, Fabian TC, Bernard AC, Fulda GJ, Hoyt DB et al. Human polymerized hemoglobin for the treatment of hemorrhagic shock when blood is unavailable: the USA multicenter trial. J Am Coll Surg 2009; 208(1):1-13. (36) Sloan EP, Koenigsberg M, Gens D, Cipolle M, Runge J, Mallory MN et al. Diaspirin cross-linked hemoglobin (DCLHb) in the treatment of severe traumatic hemorrhagic shock: a randomized controlled efficacy trial. JAMA 1999; 282(19):1857-1864. (37) Fitzgerald MC, Chan JY, Ross AW, Liew SM, Butt WW, Baguley D et al. A synthetic haemoglobin-based oxygen carrier and the reversal of cardiac hypoxia secondary to severe anaemia following trauma. Med J Aust 2011; 194(9):471-473. (38) Cotton BA. Alternative fluids for prehospital resuscitation: “pharmacological” resuscitation fluids. Journal of Trauma-Injury Infection and Critical Care 2011; 70(5):S30-S31. (39) Letson HL, Dobson GP. Ultra-Small Intravenous Bolus of 7.5% NaCl/ Mg2+ With Adenosine and Lidocaine Improves Early Resuscitation Outcome in the Rat After Severe Hemorrhagic Shock In Vivo. J Trauma 2011.

(40) Shapiro MJ. Traumatic shock: nonsurgical management. In: Parrillo JE, Dellinger RP, editors. Critical Care Medicine. 2 ed. St Louis: Mosby Inc.; 2002. 501-512. (41) Judson JA. Severe and multiple trauma. In: Bersten AD, Soni N, editors. Oh’s Intensive Care Medicine. 5 ed. Edinburgh: Butterworth Heinemann; 2003. 681-688. (42) Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007; 63(4):805-813. (43) Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 2008; 248(3):447-458. (44) Duchesne JC, Hunt JP, Wahl G, Marr AB, Wang YZ, Weintraub SE et al. Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years? J Trauma 2008; 65(2):272-276. (45) Vandromme MJ, McGwin G, Jr., Weinberg JA. Blood transfusion in the critically ill: does storage age matter? Scand J Trauma Resusc Emerg Med 2009; 17:35. (46) Weinberg JA, McGwin G, Jr., Griffin RL, Huynh VQ, Cherry SA, III, Marques MB et al. Age of transfused blood: an independent predictor of mortality despite universal leukoreduction. J Trauma 2008; 65(2):279-282. (47) Duggan JM. Blood transfusion: old blood, new blood or no blood. Intern Med J 2011; 41(4):358-359. (48) Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005; 103(1):25-32. (49) Bundgaard-Nielsen M, Secher NH, Kehlet H. ‘Liberal’ vs. ‘restrictive’ perioperative fluid therapy--a critical assessment of the evidence. Acta Anaesthesiol Scand 2009; 53(7):843-851. (50) Tisherman SA, Barie P, Bokhari F, Bonadies J, Daley B, Diebel L et al. Clinical practice guideline: endpoints of resuscitation. J Trauma 2004; 57(4):898-912. (51) Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 2002; 97(4):820-826. (52) Gonzalez E, Pieracci FM, Moore EE, Kashuk JL. Coagulation abnormalities in the trauma patient: the role of point-of-care thromboelastography. Semin Thromb Hemost 2010; 36(7):723-737. (53) McKinley BA, Marvin RG, Cocanour CS, Moore FA. Tissue hemoglobin O2 saturation during resuscitation of traumatic shock monitored using near infrared spectrometry. J Trauma 2000; 48(4):637-642. (54) Crookes BA, Cohn SM, Bloch S, Amortegui J, Manning R, Li P et al. Can near-infrared spectroscopy identify the severity of shock in trauma patients? J Trauma 2005; 58(4):806-813. (55) Cammarata GA, Weil MH, Castillo CJ, Fries M, Wang H, Sun S et al. Buccal capnometry for quantitating the severity of hemorrhagic shock. Shock 2009; 31(2):207-211. (56) Yuruk K, Almac E, Bezemer R, Goedhart P, de MB, Ince C. Blood transfusions recruit the microcirculation during cardiac surgery. Transfusion 2011; 51(5):961-967. (57) Ikossi DG, Knudson MM, Morabito DJ, Cohen MJ, Wan JJ, Khaw L et al. Continuous muscle tissue oxygenation in critically injured patients: a prospective observational study. J Trauma 2006; 61(4):780-788. (58) Burns JM, Sing RF, Mostafa G, Huynh TT, Jacobs DG, Miles WS et al. The role of transesophageal echocardiography in optimizing resuscitation in acutely injured patients. J Trauma 2005; 59(1):36-40. (59) Ferrada P, Murthi S, Anand RJ, Bochicchio GV, Scalea T. Transthoracic focused rapid echocardiographic examination: real-time evaluation of fluid status in critically ill trauma patients. J Trauma 2011; 70(1): 56-62. (60) Rippey JC, Royse AG. Ultrasound in trauma. Best Pract Res Clin Anaesthesiol 2009; 23(3):343-362.

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review article

Primary Headache Management In Military Medicine Commander Roy G Beran RANR

Commander Beran is a consultant neurologist and accredited sleep physician; professor in the School of Medicine, Griffith University, Queensland; conjoint associate professor of medicine, University of New South Wales; President of the Australasian College of Legal Medicine; Secretary General of the World Association for Medical Law; and consultant neurologist to the ADF. Within neurology, he is a member of the Australian & New Zealand Association of Neurologists, corresponding fellow of the American Academy of Neurology, member of the editorial board of a number of national and international journals and is the principal investigator of Strategic Health Evaluators, a private research company. Correspondence: royberan@unsw.edu.au Conflict of Interest There is no conflict of interest with the preparation of the paper. The author has received research grants, travel subsidies and/or honoraria from numerous pharmaceutical companies, including but not limited to: Bayer Schering, Biogen, Boehringer Ingelheim, GlaxoSmithKline, Merick Serono, Novartis, Pfizer, Roche, Sanofi-Aventis and UCB.

Abstract Military medicine manages health issues in an otherwise young and healthy population. Headache is the most common cause for neurological consultation. The nature of headaches can change with time but most commonly encountered primary headaches include: tension-type headaches, migraines and headaches with features of both of these. History is the most valuable diagnostic tool but optic fundoscopy is mandatory to exclude raised intracranial pressure. Treatment includes interval therapy for the invasive headache (with simple analgesics or anxietolytics for tension-type headaches, ergots or triptans for migraines and either of these approaches for tension-vascular headaches). Prophylaxis is with tricyclic antidepressants for tension-type headaches, pizotifen for migraines and beta blockers, like propranolol, for tension-vascular headaches. Most important, within military medicine, is the need to appreciate and address the psychological factors that accompany and may provoke tension-type headaches. These are by far the most common form of headaches necessitating medical consultation. Early and effective involvement of counselling is imperative to facilitate optimal patient care and overall efficiency.

Keywords: Military Medicine, Primary Headache, TensionType Headache, Migraine, Tension-Vascular Headache, Counselling, Treatment

Introduction Headache is by far the most common complaint to motivate neurological consultation (1). Nowhere is this more apparent than for the neurologist working within the military medicine environment. This is basically because military medicine is more attuned to the medical management of the otherwise healthy patient (2). Military medicine deals with the management of conditions that occur within a hazardous environment (3, 4). Such consequence include: direct response to trauma; being injured by foreign bodies, such as bullets or shrapnel from explosive devices; working with heavy or noisy machinery; working in an environment causing abnormal pressure affects,

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such as flying at high altitude or diving to depths; or exposure to noxious agents with nuclear or biological weapons(3,4). It follows that the emphasis in military medicine is on trauma management, surgery and the general practice that is relevant to the care of an essentially healthy young population. Often the psychological factors associated with the response to constant danger or even the consequences of boredom or loneliness are down played, if not ignored, by clinicians. Many patients who present with headaches, particularly within the military environment, think they have very serious ailments. It is the role of the neurologist to ascertain the nature, cause and management of those headaches. What follows in this paper is an analysis of primary headaches and their management within the military medicine environment.

OVERVIEW OF HEADACHES Headache already has been identified as the most common provocateur for neurological consultation (1). There is an international classification of headaches, produced by the International Headache Society (IHS), which provides taxonomy of primary headaches (5). This provides an international consensus for headache research, to ensure that there is a common understanding amongst researchers when trying to better appreciate headache pathophysiology. This is less relevant to the coalface clinician and probably even less so within the context of military medicine. There has been an effort to simplify the understanding of headache, to make it more germane to general practice (6). Recent studies have explored such issues as the management of Chronic Daily Headache (CDH) (7, 8), the most refractory form of headache, defined by frequency and duration of headache rather than a specific headache type. CDH is not properly covered in the IHS classification (5). One study of CDH (8) explored the evolution of headaches over a period of more than 20 years. It demonstrated that the nature and classification of headaches may change over their natural history (8). Within the study, neurologists classified patients as experiencing migraine, at the onset of their headache history, yet 20 years later, these same neurologists classified many of these same patients as experiencing headaches that were indistinguishable from tension-type headaches(8). This suggests that the quality and nature of headaches may change throughout their natural history. The fact that headaches may change in quality and character adds credence to the less scientific notion of headaches representing a continuum of symptoms. This suggests a clinical perspective in which tension-type headache is at one end of the spectrum, migraine is at the other and a concept

Continuum of Headaches Migraine   Tension/Vascular   Tension < --------- --- > < | ><------------------------>    ^   ^       ^ Figure 1 A continuum of headaches from tension-type headaches to migraines with tension-vascular headaches somewhere between the two, reflecting that headaches can move up and down the continuum.

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of tension-vascular headache, something not included in the IHS classification,(5) being in the middle (6) (Figure 1). This simplifies a therapeutic approach to the management of primary headaches with the adoption of three therapeutic algorithms. The treatment options include that for migraine treatment, treatment of tension-type headaches and the treatment of a headache type that does not fit comfortably into either of these categories, with features of both migraine and tension-type headache (6). This discussion has focused specifically on primary headache types. It has not considered secondary or symptomatic headaches. It seems tautological, within the context of headaches and military medicine, to discuss headaches consequent to traumatic brain injury, which should be selfexplanatory. Similarly, headaches resultant from infection or malignancy, have not featured in this review but they always must be included within consideration of the potential differential diagnoses. It is anticipated that most of these symptomatic headaches will be self evident, if not on history and examination, then on the basis of investigations which might include cerebral imaging or lumbar puncture, amongst other tests. Symptomatic or secondary headaches were deemed extraneous to the purpose of this review, which was to focus specifically on primary headaches that present to a neurological outpatient service, within the context of military medicine.

DIAGNOSIS The tool that is most necessary for the diagnosis of primary headache is no different to the tool that is necessary for any other neurological diagnoses, namely an adequate history (9). A detailed history is the foundation of proper neurology. An example of this is the sudden onset of excruciating and severe pain, especially in the neck, associated with vomiting and debilitating, blinding pain, which must raise concern about subarachnoid haemorrhage. To diagnose the headache type, the clinician needs to know: the length of history; the nature of the headache; the situation in which the headache occurs (provocative situations); the site of the headache, be it unilateral, bilateral, retro-orbital, occipital or specifically focal; the quality of the pain, be it suddenly stabbing, constant or pulsating; associated features, such as visual symptoms or gastrointestinal disturbance; precipitating factors (such as foods, lights or stress); relieving factors; frequency of headaches; and duration of those headaches. A frontal, occipital or vertex headache that is bilateral and constant in nature and unassociated with ocular or gastrointestinal features, other than perhaps some blurring of vision or possibly some minor nausea without vomiting, is, more likely than not, going to be a tension-type headache. Often the patient may have difficulty identifying precipitating or relieving factors. The patient who has greater insight may recognise stress as a provocative factor and sleep as having therapeutic benefit. A unilateral, pulsating headache, associated with teichopsia (zigzag lines bounding a luminous area in the visual field), fortification spectra (seeing a dark patch with zigzag lines like the top of a cavalry fortress), photophobia (intolerance of bright lights), phonophobia (intolerance of loud sounds) and possibly osmophobia (intolerance of smells/odours), together

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with nausea, vomiting and some relief following vomiting, is more likely to be migrainous in nature. A family history is less helpful in differentiating migraine from tension-type headache. A long history of headaches, over many years, lends weight to tension-type headaches, in preference to migraine, but is also of limited differential value. Often the patient is under the misapprehension that the severity of the headache is the deciding factor. The patient believes that a more severe headache must be migrainous or symptomatic in nature and this is far from true. Those patients whose features include some of both the tension-type constellation and those more relevant to migraines, but do not fit into either category satisfactorily, fall into that arbitrary convenience category of tension-vascular headache, as suggested above but not included in the IHS classification. The importance of a good physical examination should not be underestimated, especially the need for proper fundoscopic examination of the eyes. The presence of venous pulsations excludes the presence of raised intracranial pressure and thus limits the risk of space-occupying lesions. It follows that fundoscopy should be a fundamental component of all physical examination of patients with headaches. Focal neurological signs raise the ‘red flag’ for symptomatic, secondary headaches. Most often the patient who presents with headache has no focal neurological signs and the diagnosis is based solely on history.

TREATMENT Tension-type headaches are far more common than are migraines (10) and a confident diagnosis of tension-type headache, with associated reassurance, should have high therapeutic benefit. This is not always the case and such diagnosis may be vehemently rejected, particularly within the military medicine context. There are specific issues regarding tension-type headaches and military medicine, which will be discussed below. Prolonged tension type headaches respond to prophylaxis with tricyclic antidepressants. Amitriptyline, starting at a low dose of 25 mg at night, has a greater potential for sedation and hence is more valuable in patients who report disturbed sleep in association with their headaches. Imipramine, also starting at a low dose of 25 mg at night, is less sedating and thus more beneficial for patients who deny sleep disturbance in association with their tension-type headaches. Interval treatment for tension-type headaches may be as simple as the use of paracetamol or other commonly used analgesics. Shortacting anxietolytics, such as the benzodiazepines, (for example lorazepam given as 1 – 2 mg stat) may provide additional benefit to relieve tension-type headaches. It is important to appreciate the potential addictive nature and tolerance that attaches to benzodiazepines, particularly in patients who have tension-type headache, which may reflect the presenting symptoms of underlying psychological problems. Migraines respond to the early intervention with either medications including ergot derivatives, possibly in combination with other agents such as caffeine, or alternatively with triptans. Prophylaxis may be provided using pizotifen given in adequate doses. It is important to appreciate that while pizotifen (starting at a low dosage of 0.5 mg given twice daily.) offers very

effective prophylaxis for migraine, it is far less effective in the treatment of tension-type headache and thus differentiation between migraine and tension-type headache is fundamental to the choice of optimal treatment. Tension-vascular headaches respond to interval therapy as per tension-type headache or migraine, plus judicious use of propranolol (starting at a low dose of 40 mg ½ twice daily.) as effective prophylaxis. As with the use of the tricyclic antidepressants, the use of pizotifen or beta blockers, such as propranolol, it is important to appreciate that the doses must be adequately titrated to the patient’s need before efficacy is achieved. Maximum doses as high as 250 mg of tricyclic antidepressants, given as a single dose nocturnally; 4.5 mg of pizotifen given in divided doses three times daily.; or 160 mg of propranolol given four times daily. (up to 640 mg per day) may be required before efficacy is achieved. It is imperative to ‘start low and go slow’ with incremental increases titrated to need but to recognise that failure of therapy is often not the result of the use of inappropriate medications but rather a lack of achieving the adequate dosage necessary for the individual patient(6). Clear understanding of the adverse drug effect profile of each medication is mandatory, especially the potential for propranolol to exacerbate heart failure or asthma (the latter being more likely within the military medicine context). Patients need to be advised of these potential adverse events and same documented in their medical records. Those receiving tricyclics should be warned of delayed response, taking up to two weeks, irrespective of adverse effects being experienced.

SPECIFIC MILITARY MEDICINE CONSIDERATIONS The foregoing reviewed diagnosis and treatment of the most common primary headaches encountered within both the community in general and military medicine in particular. It adopted a broad-brush approach but avoided specific consideration of military medicine. This recognised that primary headaches, which occur within the military context, are no different to those which occur within the general community. What is different, within military medicine, is the overarching emphasis upon the need for physical fitness and a healthy attitude (11). An underlining pre-requisite is for service personnel to maintain psychological strengths, which are as important to efficiency as is physical fitness. Emotional stability and strength are considered a fundamental pre-requisite, while stamina and endurance are potentially achievable through physical training (12). Emotional wellbeing is less well understood amongst military personnel because it is less quantifiable and hence is more abstract (13). Physical fitness is more obvious and results from factors imposed from without and hence physical complaints may be perceived as more amenable to intervention. Conversely, psychological or emotional complaints are seen as an idiosyncratic personality flaw, which translates into diminished reliability and dependability (14). It follows that a headache caused by a physical problem may be considered more acceptable to service personnel than is a similar headache provoked by stress or tension. Service personnel often prefer to present with a complaint of a physical nature, rather than one potentially of emotional

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aetiology (15). It follows that the clinician must first confirm the diagnosis of tension-type headache and then must explore the potential causes for same, not ignoring the very real stresses and emotional factors that occur in the patient’s circumstances. Appropriate management may necessitate the early involvement of a counsellor, psychologist or psychiatrist. Early recognition and identification of potential psychological factors may expedite earlier acceptance of intervention and better therapeutic outcome. Such intervention does not negate the previously discussed approach to the routine management of tension-type headaches with the judicious use of tricyclic antidepressants for prophylaxis. These may have additional benefits, beyond headache management, as they are antidepressants as well as muscle relaxants, hypnotics, tranquillisers and pain relievers. One should not ignore that the use of psychotropic medications, such as antidepressants, may have a negative impact on either deployment or garrison duties. It is important to emphasise the short term nature of the medications, aimed at prophylaxis to achieve a period of headache freedom followed by judicious withdrawal upon proven efficacy and headache relief.

The notion that headache is perceived as a physical complaint makes the presentation with headache, even if ultimately diag­nosed as tension-type headache, a more acceptable way to call for help. The discussion thus far has adopted a holistic approach, but this ignores that the ‘whole’ is made up from its individual parts. The importance of the whole of the defence force is paramount, over the needs of the individual. This leaves the individual vulnerable when contemplating assistance for personal psychological factors. This, in turn, requires an extra level of awareness on the part of the attending clinician. Often the busy clinician lacks the time and expertise to adopt a more individualised approach. The pragmatic clinical concept of ‘diagnose and treat’ is also more attuned to physical conditions. Tension-type headaches are relatively easy to diagnose and the prescription of immediate pharmacological intervention and prophylaxis is very straightforward. The downside is that this approach ignores the underlining reason for the member’s presentation. It does nothing to address the stressors that provoked the headaches. The provision of pharmaceuticals addresses the superficial reason for

Particularly within the mili­ tary medicine context, which operates within a rigid hier­ archical structure, it is impera­ tive to not only make the fundamental diagnosis, such as tension-type headache, but also to be receptive to other fundamental problems which may contribute, such as work related factors. Early intervention must also be cog­ nizant of the career factors. The clinician needs to try to avoid the fracturing and dis­ location of service careers. These rely upon the individual being accepted both by peers and within the hierarchical structure, which may underpin the headaches People within the military often feel disempowered due to a perceived lack of con­ trol of their own future. Issues of appreciation and res­ pect by superior ranks are often identified as causing frus­ tra­ tion. A lack of equality between expecta­tion and real­ isation of what the job entails is also frequently a source of dissatisfaction. Other factors, such as the competing demands from work and family is an additional consideration when evaluating possible causes for stress and dissatisfaction. ADF Health | Vol 12 No. 1 | 2011

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Headache remains the leading cause for seeking neurological consultation, both within and without military medicine.

presentation but ignores the more likely underlying problem for which the member also sought help, although he/she may not have admitted same, even to him/herself. The reason why young men and women join the defence forces is often unique to that individual. Some join to maintain a proud family tradition of serving their country. Others join to run away from an abusive or hostile home environment. There are many other reasons for enlisting and their identification may provide the basis for effective intervention. Often a glamorous “Hollywood” image bears no relationship to the reality that is encountered within the forces. Identifying these issues may necessitate involvement of a specialist trained in this area The member who presents with tension-type headache may not be aware that the headache represents a more acceptable method of calling for help. The member is subject to the same influences, regarding the physical versus the psychological issues, as exist throughout the defence forces. The member may actively reject any notion that pain, hence perceived as a physical complaint, can be anything other than a physical complaint. This may present the first impenetrable barrier to the provision of appropriate intervention. It is at this level that the clinician may serve a most valuable therapeutic role. The member needs to accept the wisdom of involving a counsellor and the clinician has the capacity to open this door. The clinician provides an invaluable bridge between the diagnosis and the teasing out of the real underlying problems and hence provision of therapy. The patient with tension-type headaches still has pain and is still in need of physical help. The use of tricyclic antidepressant medications is still a useful tool in the headache management. It is not an ‘all or nothing’ phenomenon. What is required is a partnership between the doctor and counsellor (not ignoring the fact that the counsellor also may be a doctor). This allows the maintenance of self-respect as well as the respect from peers as there remains an acceptance of the physical complaint of tension-type headaches. What it offers is the opportunity for a two-pronged attack, which treats both the presenting complaint while concurrently addressing the underlying root cause.

CONCLUSIONS Headache remains the leading cause for seeking neurological consultation, both within and without military medicine.

The approach to diagnosis and treatment of primary headaches is the same, both within and without military medicine. There is a major difference between military medicine and civilian medicine in that in the military there is potentially a greater imbalance between the relevance associated with physical, as compared to emotional/psychological complaints. An early appreciation of potential psychological factors, which are fundamental to the aetiology of tension-type headaches, particularly within the military medical environment, will allow far more effective and efficient intervention. Early involvement of councillors, psychologists or psychiatrists may better assist in the maintenance of career paths and a more satisfactory overall outcome. This does not exclude the appropriate use of pharmacological agents but aims to balance these with adjunctive counselling for better people management and prognostic outcome both for the individual patient and for the service in which that patient operates.

REFERENCES 1.

Dodick DW. “Clinical clues and clinical rules: primary vs. secondary headache” Adv Stud Med; 3:S550–S555, 2003

2. Bleier J, Waller M, McGuire A, Treloar S, McFarlane A, Dobson A “the near north area of influence study group: comparison of health outcomes for personnel who had not been on a military deployment compared with those who had been to East Timor and the Middle East area of operations” J Military and Veterans’ Health; 18 (1):9, 2010 3.

Martinowitz U, Zaarur M, Yaron BL, Blumenfeld A, Martonovits G “Treating traumatic bleeding in a combat setting: possible role of recombinant activated factor VII” Mil Med Dec 169 (12 Suppl): 16 – 8, 4, 2004

4.

Baker MS “Creating order from chaos: part 1: triage, initial care, and tactical considerations in mass casualty and disaster response” Mil Med Mar: 172 (3): 232 – 6, 2007

5.

Headache Classification Subcommittee of the International Headache Society “The international classification of headache disorders”. (2nd edition) Cephalalgia 24 (Suppl 1): 9–160, 2004

6.

Beran RG “Headache” Medical Observer 9 May: 31 – 33, 2008

7.

Spira J P and Beran RG “Gabapentin in the prophylaxis of chronic daily headache: A randomized, placebo-controlled study”. Neurology 61(12):1753-1759, 2003

8.

Beran R G and Spira P J “Levetiracetam in chronic daily headache: a double-blind, randomised, placebo-controlled study (The Australian Keppra Headache Trial [AUS-KHT])” Cephalalgia 31 (5): 530 - 536; 2011

9.

Beran RG Neurology for GPs Elsevier, Sydney, 2011 (In Press)

10. Fong, K-Y J. “Recent advances in the diagnosis and management of primary headache disorders”. Medical Session June 2002. Available at: http://www.fmshk.com.hk/article/821.pdf (accessed 25 March 2008) 11. Council PaNR. Assessing Fitness for Military Enlistment: Physical, Medical and Mental Health Standards. In: Sackett PR, Mavor AS, editors. Washington: The National Academies Press; p1, 2006 12. Roy TC, Springer BA, McNulty V, Butler NL. Physical Fitness. Military Medicine; 175:14-20, 2010 13. Matthews F, Stone D, Williams P. Achieving health and human development: VCE units 1 and 2. Melbourne: Macmillan Education; p25, 2003 14. Pflanz SE, Ogle AD. Job Stress, Depression, Work Performance, and Perceptions of Supervisors in Military Personnel. Military Medicine; 171(9):861-5, 2006 15. Bergen Lv. Before My Helpless Sight: Suffering, Dying and Military Medicine on the Western Front, 1914-1918 (The History of Medicine in Context). Ashgate Publishing; p. 404, 2009

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occupational health and safety

Radiation hazards and fertility. What do we know? Lieutenant Commander Steve Robson RANR

LCDR Robson joined the RAN as an undergraduate in 1986, and served in the PNF from 1989-91. He was medical officer in HMA ships ALBATROSS, SUCCESS, and SYDNEY, and served in the first Gulf War. He is currently Associate Professor in Obstetrics and Gynaecology at the Australian National University in Canberra. His special research and clinical interests include male fertility and stillbirth. Correspondence: Associate Professor Steven Robson, Australian National University Medical School, TCH Campus, PO Box 5235, Garran ACT 2605

Introduction Warships of the Royal Australian Navy (RAN) are equipped with various sources of radio frequency (RF) energy, including communications antennae, radar equipment and aircraft sources. Indeed, this situation applies to other Defence assets as well. However sailors, because of confined space below decks and the presence of fuel and ordnance find that the only opportunity for fresh air and space is on upper decks in close proximity to RF sources. This has the potential for near-field exposures to non-ionizing radiation hazards (RADHAZ). Many anecdotal stories are shared by sailors and other personnel about the supposed effect of RADHAZ on health, most commonly on their ‘fertility.’ This article reviews the known biological effects of non-ionizing radiation on humans, and any potential effects on fertility.

Non-ionizing radiation Radiation forms such as ingestion of medical isotopes, X-rays, and gamma rays are sufficiently energetic to cause ionization in tissues (hence the term ionizing radiation) and are associated with the development of malignancy and other adverse health effects in humans. The more common forms of energetic radiation encountered in occupational and other settings include RF (or microwave) radiation and extremely low frequency (ELF) radiation. ELF radiation, at about 60 cycles

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per second, is the type encountered in the presence of hightension power lines. ELF and its association with adverse health effects will not be considered here. The widespread use of mobile telephones and other hand-held devices such as iPads with Internet connectivity mean that many people are in regular close proximity to relatively intense RF energy emissions, and this has prompted further study into its biological effects. Apart from the ubiquitous mobile telephone or iPad, military personnel commonly work in proximity to radars (which radiate microwaves) or communications antennae. In ships, radars are usually mounted so as not to irradiate the decks or superstructure, but communications antennae mounted on the superstructure can give rise to so-called ‘hot spots’ from resonances and re-radiation. RADHAZ footprints are carefully mapped and marked on decks around antennae and other high-energy sources as exclusion zones. Radiation in the RF range does not affect DNA, but it does have the potential to cause heating of tissues. The evidence regarding biological effects of RF energy have been well summarized by Goldsmith (1) and I quote his findings here, although readers are encouraged to consult the paper. Of relevance to reproductive effects, Goldsmith quotes two sources. A study comparing female physiotherapists who did or did not use RF or shortwave therapy apparatus during the first trimester of pregnancy, usually with exposures for only a few minutes at a time, revealed increased odds for miscarriage in the first trimester. The odds increased with increasing exposures. (2) The other, a study of embassy personnel who worked in proximity to RF sources, reported an increased rate of pregnancy complications.(3) In addition to these suggestions of adverse reproductive effect, other biological effects have been reported: shifts in red and white cell counts; increased rates of malignancy; and increased somatic mutation rates in lymphocytes. Some of these effects have been noted previously in a report from Australian Defence Force (ADF) personnel with accidental exposure to microwave radar irradiation. (4)

Fertility in military personnel Before discussing any real or potential effects of RF radiation exposure on the reproductive potential of Defence Force personnel, it is important to review what is known about the

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normal ‘fertility’ of this population. Making such assessments is not as easy as it might appear. The accepted measures of ‘fertility’ in women are twofold. Fecundity is the probability of pregnancy in each month of mid-cycle intercourse, and although it is typically about 25% in healthy young women not using contraception, is influenced strongly by many factors, including the age of the woman and stress (which is associated with anovulation, and indeed reduced sexual receptivity). When pregnancy occurs, the rate of miscarriage is also an important factor and this increases with age. The definition of ‘fertility’ in males is more difficult, and results of semen analysis cannot be used as a surrogate measure of fertility. A useful working definition of male fertility is, the ability of a man to consistently make and deliver sufficient numbers of normal sperm into the female reproductive tract at the fertile time.(5) Unfortunately, studies using such a definition have never been undertaken. The results of semen analysis are notoriously variable, and even fertile men will commonly have surprisingly disappointing semen parameters.

Effects on Semen The potential effects of military service per se on reproductive health have been addressed previously in this journal (6), but important data have become available since that time. A study of US Army soldiers who worked with radar revealed that many of them were concerned about their exposures and the potential effects on their fertility. (7) Such a finding will surprise no one. Although measures of endocrine function showed no differences between the exposed and control groups, it was noted that soldiers with microwave exposure had significantly lower sperm concentrations in their ejaculates. Interestingly, the soldiers who were most concerned about their fertility were found to have lower sperm concentrations and the reason for this finding was not clear. The sample sizes were small and it is difficult to draw a conclusion from the study. A more recent and larger study from China examined sailors exposed to radar, and examined sperm concentrations, motility and morphology in the study subjects. The study reported that radar exposure was associated with reductions in sperm motility and increased proportions of abnormal sperm. (8) However, cessation of exposure resulted in rapid recovery of sperm morphology parameters. A larger study of US soldiers, however, reported no association between radar exposure and either hormonal or semen analysis parameters. (9) The data available are from small groups and the results are contradictory.

Gulf War exposures. If exposure to active military service does affect fertility, it might be reasonable to ask what larger cohort studies have revealed about fertility during active service. A number of studies have examined reproductive outcomes of veterans of the 1991 Gulf War. A retrospective study was undertaken of all British armed forces personnel deployed to the Gulf War, comparing them with serving personnel deployed elsewhere. Notwithstanding the differing response rates to the surveys, the study found significant increases in self-reported infertility in the Gulf War veterans group that were robust.(10) When reproductive outcomes in the cohort were examined, no association was found between service in the Gulf War

and stillbirth, chromosomal abnormalities, or any specific syndromes.(11) A survey of United States Gulf War veterans revealed no significant differences in self-reported adverse pregnancy outcomes in men or women compared to control groups.(12) A very similar study of French Gulf War veterans did not identify any tendency to infertility or adverse pregnancy outcomes in the study group.(13) A cross-sectional study of over 1400 male Australian Gulf War veterans was undertaken with a control group of similar size comprising randomly-selected military personnel without the exposure. This was conducted by postal survey with questions relating to fertility delays, pregnancy outcomes including live birth, stillbirth, miscarriages, and other pregnancy losses. For live births, data were obtained regarding sex of the offspring, birthweight, and serious health problems in the progeny. No differences were detected in the rate of adverse outcomes between the groups, although there was a marginally significant trend to fertility delays in males in the Gulf War veterans’ group. (14) The difficulty with such retrospective surveys is the self-selected nature of the responses and the consequent difficulty of applying the data more generally. Pregnancy after RADHAZ exposure. Assuming that exposure to non-ionizing radiation in particular, and active service in general is not associated with subsequent fertility problems; it is also worth examining the effect of such exposures on longer-term pregnancy outcomes. It has already been shown that some data suggest there may be an effect on miscarriage rates. (2, 3) A potentially common situation is inadvertent exposure to radiation before the diagnosis of pregnancy has been made, so this is usually in the first trimester. While it is well-recognised that such exposure to ionizing radiation (X-rays, for example) is associated with teratogenesis that is dose-dependent, fortunately no such association has been found for non-ionizing radiation exposures.(15)

Discussion Non-ionizing radiation hazards, usually from radar and communications equipment, are well recognized in both military and civilian occupational settings. Mapping of such hazards is routinely undertaken and exclusion zones are usually well-marked and adhered to. Positioning of such apparatus is undertaken to minimize risk. Additional effects, such as re-radiation and resonances around communications equipment, are also recognized and such ‘hot-spots’ are usually well-known and marked. The typical setting in which inadvertent exposure occurs is during a breakdown in protocols: personnel are present in danger zones during use of equipment or radiation from radar equipment. Temporary biological effects, most likely from microwave heating, are well recognized and temporary with little evidence of cumulative, chronic effects. Studies of ‘fertility’ in military personnel to date suffer from major methodological problems – they are typically retrospective (often by many years), there is little or no dosimeter or estimation of exposure, participants are commonly self-reporting which leads to bias, and definitions of ‘fertility’ or ‘infertility’ are difficult to standardize. When objective measures are used, such as semen analysis parameters or serum hormone levels, these are notoriously variable and

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difficult to compare. Since occupational regulations are in place to minimize exposure, it is unlikely that reliable large scale data will ever be available. The large studies from military populations who would be expected to have the highest risk of inadvertent exposure (that is, during war) are reassuring, with no evidence of differences in fertility or pregnancy outcome between exposed and control groups.

Conclusion Safety concerns harboured by personnel who are working close to RADHAZ equipment are understandable. However existing safe working protocols are likely to be effective. In cases of inadvertent exposures to radar or RF transmissions, biological effects (presumably from microwave heating or similar) are likely to be temporary and there is no evidence of a long term adverse effect on fertility or pregnancy outcome.

References

4. Robson S, Donovan K. Interesting haematologic responses to microwave exposure. Aust Mil Med 1995; 4: 10 - 13. 5.

Robson S. Male fertility. O&G Magazine 2010; 12: 47-50.

6.

Robson S. Combat related military roles and early pregnancy. Aust Mil Med 1994; 3: 7 - 9.

7.

Weyandt TB, Schrader SM, Turner TW, Simon SD, Semen analysis of military personnel associated with military duty assignments. Reprod Toxicol 1996; 10: 521-8.

8.

Ye LL, Suo YS, Cao WL, Chen M. Radar radiation damages sperm quality. Zhonghua Nan Ke Xue 2007; 13: 801-3.

9.

Schrader SM, Langford RE, Turner TW, et al. Reproductive function in relation to duty assignments among military personnel. Reprod Toxicol 1998; 12: 465-8.

10. Maconachie N, Doyle P, Carson C. Infertility among male UK veterans of the 1990-91 Gulf War: retrospective cohort study. BMJ, doi:10.1136/ bmj.38163.620972.AE (published 14 July 2004) 11. Doyle P, Maconachie N, Davies G, et al. Miscarriage, stillbirth and congenital malformation in the offspring of UK veterans of the first Gulf War. Int J Epidemiol 2004; 33: 74-86.

Goldsmith JR. Epidemiologic evidence relevant to radar (microwave) effects. Environ Health Perspect 1997; 105 (Suppl 6): 1579-87.

12. Wells TS, Wang LZ, Spooner CN, et al. Self-reported reproductive outcomes among male and female 1991 Gulf War era US military veterans. Matern Child Health J 2006; 10: 501-10.

2. Ouellet-Hellstrom R, Stewart WF. Miscarriages among female physiotherapists who report using radio- and microwave frequency electromagnetic radiation. Am J Epidemiology 1993; 138: 775 â&#x20AC;&#x201C; 786.

13. Verret C, Jutand MA, Vigan C, et al. Reproductive health and pregnancy outcomes among French Gulf War veterans. BMC Public Health 2008; 8: 141.

3.

14. Kelsall HL, Sim MR, Ikin JF, et al. Reproductive health of male Australian veterans of the 1991 Gulf War. BMC Public Health 2007; 7: 79.

1.

Lilienfield AM, Tonascia J, Tonascia S, et al. Foreign Service health status study: evaluation of health status of Foreign Service and other employees from selected Eastern European posts. Final report contract 6025-619073 (NTIS PB-288163). Washington: US Department of State, 1978. Quoted in 1.

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15. Williams PM, Fletcher S. Health effects of prenatal radiation exposure. Am Fam Physician 2010; 82: 488-93.

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clinical quiz

A Soldier with Fever and a Rash Lieutenant Colonel Peter A Leggat

Lieutenant Colonel Peter Leggat, RAAMC, joined the Australian Regular Army in 1987. He was posted to various units, including the historic 2 Field Ambulance in Townsville. Lieutenant Colonel Leggat is currently serving as a Consultant, Defence Health Service, Army Reserve, Queensland. In 2002, he was awarded the Major General John Pearn Surgeon Generalâ&#x20AC;&#x2122;s Medal for outstanding contributions to tropical medicine. He was also President of The Australasian College of Tropical Medicine from 1996 to 1998, from 2002 to 2004 and from 2006-2008. He is currently Deputy National Director of Training for St John. School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, QLD. Peter A Leggat, MD, FAFPHM, Professor. Correspondence: Lieutenant Colonel Peter A Leggat, School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, QLD 4811. peter.leggat@jcu.edu.au

In May 2011, a 37 year old male soldier presented with a sudden onset of fever, retro-orbital headache, arthralgia, myalgia, some nausea and fatigue. On examination, the patient had a widespread rash, including the trunk (A, B). There was no history of overseas travel, but the soldier had been in the Cowley Beach Training Area, near Innisfail, North Queensland, and then in Cairns for a few days before returning to Townsville, where he presented unwell.

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clinical quiz – ANSWER A Soldier with Fever and a Rash Diagnosis: This patient had probable dengue. Initial Investigations: Full blood count revealed a slightly lowered white cell count (3.8; ref. 4.0-11), a slight lymphocytopenia (0.7; ref. 1.1-4.0), and a thrombocytopenia (66; ref. 150-450). He was also positive on a Dengue NS1 antigen rapid test. Additional history: The soldier had been taking daily doxycycline for prevention of scrub typhus. Discussion: His visit to Cowley Beach certainly raises the possibility of scrub typhus, as this is a known area for previous outbreaks amongst military personnel.(1–3) It could have represented a failure to his prophylaxis and scrub typhus was also investigated as a diagnosis. However, north Queensland is also an area where there are frequent outbreaks of dengue, which is often brought in by travellers and spreads quickly amongst the local population.(4) Outbreaks of all four serotypes of dengue (DEN-1, DEN-2, DEN-3 & DEN-4) has been seen in recent years in northern Queensland, as the vector, Aedes aegypti, is widespread in this region.(4) At the time of presentation, there were three dengue outbreaks declared in north Queensland, namely in Cairns (DEN-4), Innisfail (DEN-4 and DEN-2) and Townsville (DEN-1).(5) These outbreaks are now declared over.(6) Infection with dengue virus can range from no apparent symptoms to a mild to moderate illness (dengue), or sometimes even a potentially fatal condition, i.e. dengue haemorrhagic fever (DHF) or dengue shock syndrome (DSS),(4) which may be related to subsequent infections with a different dengue serotype. The symptoms of dengue usually come on between 4-7 days after exposure, but can be an earlier or later onset, and symptoms can last up to a week. There is sometimes quite a florid macular or maculopapular rash a few days after the onset of fever and other symptoms.(4) The detection and successful typing of dengue virus from patients with suspected dengue is important both for the diagnosis of the disease and also for the implementation of public health control measures. The development of rapid tests to detect the non-structural protein (NS1) has greatly improved early diagnosis of dengue.(7) NS1 is an antigen localized on the surface of cells infected with dengue virus that is common to the four dengue serotypes and is detectable between the first and ninth days after the onset of fever.(7) NS1 rapid tests kits are being increasingly promoted for first-line testing for acute dengue infection in clinical diagnostic laboratories. Its sensitivity is around 89% and it appears to be 100% specific.(8) Definitive dengue tests include dengue serology (acute and convalescent samples to detect antibodies) and serum dengue PCR (particularly used if early in the illness). Treatment and Prevention: Treatment of dengue is symptomatic and supportive and usually involves paracetamol and adequate

oral and supplemental intravenous hydration, while carefully following relevant parameters such as the haematocrit, platelet count and tourniquet test for any evidence of DHF/DSS,(9) as was largely the case with this patient. Aspirin and nonsteroidal anti-inflammatory drugs are avoided, because it can aggravate bleeding.(7,9) Public health management is directed at preventing transmission, where suitable vectors are present, which is certainly the case in Townsville. Dengue is a notifiable disease in Queensland and suspected dengue on clinical/ provisional grounds requires notification by clinicians.(10) In north Queensland, there is an ever present risk of importation of dengue from soldiers, which must be well managed.(11) The Australian Defence Force experienced a significant exposure to dengue during its deployments to Timor Leste.(12) Until a suitable dengue vaccine becomes available, where there has been some progress,(12) personal protective measures remain the first line of defence against dengue.(4)

References 1.

McBride WJ, Taylor CT, Pryor JA, Simpson JD. Scrub typhus in north Queensland. Med J Aust 1999; 170: 318-320.

2.

Likeman RK. Scrub typhus: a recent outbreak among military personnel in north Queensland. ADF Health 2006; 7: 10-13.

3.

Leggat PA. A soldier with a fever and a rash. ADF Health 2006; 7: 67, 91.

4.

Leggat PA. Dengue in northern Queensland, Australia: Risk from travellers or risk to travellers. Travel Med Inf Dis 2009; 7: 212214.

5.

Queensland Health. Outbreak Update. Previous outbreaks in north Queensland. Dengue in north Queensland. Last updated 14 June 2011. URL. http://www.health.qld.gov.au/dengue/outbreak_ update/previous.asp (accessed 9 July 2011)

6.

Queensland Health. Outbreak Update. Dengue Fever. Last updated 14 June 2011. URL. http://www.health.qld.gov.au/dengue/ outbreak_update/current.asp (accessed 9 July 2011)

7.

Teixeira MG, Barreto ML. Diagnosis and management of dengue. BMJ 2009; 339: 1189-1193.

8.

Dussart P, Labeau B, Lagathu G, et al. Evaluation of an enzyme immunoassay for detection of dengue virus NS1 antigen in human serum. Clin Vaccine Immunol 2006; 13: 1185-1189.

9.

World Health Organization. Dengue Haemorrhagic Fever: Diagnosis, Treatment, Prevention and Control. 2nd edn. Geneva: WHO, 1997. URL. http://www.who.int/csr/resources/publications/dengue/ Denguepublication/en/ (accessed 20 June 2011)

10. Queensland Health. List of Pathological, Clinical and Provisional Diagnosis Notifiable Conditions – Public Health Regulation 2005 – as at 30 October 2009. Last Reviewed 2 July 2010. URL. http:// www.health.qld.gov.au/ph/documents/cdb/notif_conditions_list. pdf (accessed 9 July 2011) 11. Kitchener S, Leggat PA, Brennan L, McCall B. Importation of dengue by soldiers returning from East Timor to North Queensland, Australia. J Travel Med 2002; 9: 180-183. 12. Kitchener S. Dengue fever update. J Mil Veterans’ Health 2010; 18: 42-43.

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readership survey

This is the second Readership Survey we have conducted. The first was in April 2005.Amongst other things that first survey encouraged us to include more practical tips on management; quizzes, field anaesthesia, and military historical perspectives. We would ask you to complete this second Readership Survey and fax it back to: 029 5873631 by 1 December 2011.Your reply will be placed in a draw for a substantial prize.

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personal viewpoint

Strategic reform of deployable mental health support Commander Geoff Waghorn RANR

CMDR Waghorn has been a member of the Active Navy Reserve since 1985 and a psychology officer since 1992. He completed his PhD in the field of psychiatric rehabilitation in 2005 and is Head of the Social Inclusion and Translational Research Team at Queensland Centre for Mental Health Research. He has an appointment as Adjunct Senior Lecturer in the School of Population Health at the University of Queensland He leads a program of research aiming to increase the social inclusion of people with severe and persistent mental illness. He has published over 70 articles and book chapters and together with international colleagues, conducts research identifying and promoting evidence-based practices in psychiatric rehabilitation. Correspondence: geoff_waghorn@qcmhr.uq.edu.au

Abstract In this paper the mechanisms for deployment of mental health support (MHS) services are considered with reference to ADF Strategic Reform principles. The author suggests a more cost effective means to develop and deliver deployable MHS. He argues that MHS teams should be augmented by recruiting new health personnel categories such as medical and nursing officers with special training and experience. By using such a strategy, surge requirements would be met.

The mental health reform agenda can be seen as part of a much larger program of strategic reform intended to improve ADF capability and efficiency through to 2030. (2) Defence personnel management is a primary target of this reform (pp 107-108). One of the personnel management reform requirements is to review of the ADF workforce mix across all functions and workplaces, in line with the total force concept, to identify where part-time uniformed (Reserve), Australian Public Service (APS), and ADF contractors, can be better utilised in preference to higher cost full-time uniformed elements.(3) Joint Health Command, through DMHPR, is currently implementing the Dunt Review recommendations which require a greater investment in and ongoing enhancements and reforms to ADF Mental Health Services and to the ADF Mental Health Strategy as a whole.(4) At present, these reforms are focussed on garrison-based services within Australia(1), and it may be some time before the role of part-time uniformed elements, or APS civilian elements, are comprehensively reconsidered, particularly with respect to how they can contribute to deployable mental health support capabilities. It is that second stage of planning that the author wishes to address. iiâ&#x20AC;&#x201A; The Problem. There are several inconsistencies between ADF personnel reform principles and the current organisation of deployable MHS teams. namely: 1. The majority of deployable MHS assets are Army

Strategic reform of deployable mental health support Introduction i. The Challenge.

Mental health reform in the ADF is gaining momentum due to a government requirement for ADF wide reform, a recent independent review, and the continuing efforts of health personnel in all services. Enabling factors include leadership from Joint Health Command through the tri-service Directorate of Mental Health, now known as the Directorate of Mental Health, Psychology and Rehabilitation (DMHPR); and ADF support for the recent Dunt Review recommendations and the allocation of $83 million in the 2009 Defence White Paper to further reform and enhance the ADF mental health strategy(1). ADF Health | Vol 12 No. 1 | 2011

2. The MHS teams are dominated by psychologists to the exclusion of ADF nurses, medical officers,psychiatrists,chap lains and APS civilian staff despite these other employment categories having often extensive and applicable MHS training and experience. 3. Scant attention is currently given to choosing staff most suited to the particular battle space viz. land, sea, air. 4. Surge plans in time of increased demand are inadequate (to the authorâ&#x20AC;&#x2122;s knowledge) .This could mean that force preservation will be interrupted once initial MHS teams need to be relieved. 5. Military MHS is fragmented and training is inconsistent. One way to begin addressing these limitations is to reassess the current system and consider how personnel elements can

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be more optimally utilised in all battle spaces (land, maritime, air and space), involving all three services and all personnel categories, namely full-time uniformed, part-time uniformed, and full-time and part-time APS civilians. This paper explores some of these limitations and how existing ADF mental health personnel might be reorganised and trained into deployable capabilities in line with current strategic and budget reform principles(3). Although there may be implications for how other ADF garrison health, rehabilitation and psychology services are organised, garrison services are not addressed. The author’s aim is to identify, candidate organisational structures under both Joint Health Command (JHC) and Joint Operations Command (JOC) which can best develop and maintain mental health support capabilities to all operational environments. The main strategic reform principle applied is that the capability be developed as efficiently and cost effectively as possible. This would exclude expensive solutions such as employing additional full-time mental health professionals, altering existing categories of service, or adjusting existing conditions of employment. A key question is: Can a more cost effective way be found to organise, raise, train, sustain, and deploy ADF mental health personnel to operations (military and humanitarian) using well defined mental health support capabilities?

The need to reform deployable mental health support i Staffing. A central theme emerging from the Dunt Review(4) and the White Paper(2) is the need to preserve military capability by increasing the readiness of ADF health personnel to operate in environments in which many seriously wounded casualties and many acute psychological casualties can be expected. The ADF continues to support the development of defined and deployable mental health support capabilities for the purpose of preserving military capability. One of these capabilities is now well developed and is known as critical incident mental health support (CIMHS). A recently revised Defence Instruction (DI)(5) summarises the evidencebased framework utilised for designing this capability. Predeployment training is provided to health personnel from several disciplines who can be deployed individually or in teams in response to commanders’ requests for support for specific critical incidents or potentially traumatic events. This defence instruction details how this capability was developed and how it shall be delivered. But no statements are made regarding cost efficiency, or what composition of health providers should be selected for specific battle space tasks. This means that the potential benefits of service specialisation, and the use of more cost effective personnel elements are not currently considered. This issue is relevant to the reform of personnel management in the ADF, because there is an opportunity to plan and identify in advance, the most optimal mix of mental health personnel elements that can be prepared for short deployments. The advent of the SRP means inter alia that the most cost-effectively trained and prepared personnel are selected for short notice deployments into Land Command, Navy (maritime) or Air Force controlled environments. A tri-Service approach to the composition of MHS teams needs to be entertained. The CIMHS defence instruction governs responses to critical incidents. But these are only one of several possible forms of mental health support: In episodes of mass casualties

high incidences of acute mental disorders can be expected. Supplementary strategies to manage such psychological morbidity could include: (1) in-theatre force preparation to minimise psychological injury during specific high risk tasks; (2) a psychological triage capability to minimise nonessential evacuations; and (3) immediate and proximal clinical treatments to reduce acute psychological distress and preserve the short-term functioning of key personnel. Factoring such plans into MHS would improve ADF force preservation.

Mental health support capability development Table 1 shows the mental health support services currently developed into deployable capabilities and some yet to be developed. To date, two forms of mental health support to operations have been fully developed into defined capabilities supported by pre-requisite training. These are Critical Incident Mental Health Support (CIMHS) and Return to Australia Psychological Screening (RtAPS). This table suggests a need for several other types of mental health support to both prevent and manage high rates of psychological casualties. A good preventative example is the promising new battle resilience training intervention, known as ‘Battlesmart’, currently being trialled by Army(6) with the intention of wider application in the ADF. There is also an urgent need to develop psychological casualty triage, and to develop in-theatre clinical interventions to counter acute individual stress as a means of preserving military capability. Not to develop such strategies would mean continuing deployments of mental health qualified personnel to operations, or to units participating in operations, in the hope that these personnel will respond appropriately to the particular challenges and situations encountered. For instance Army, but not Navy or Air Force to the author’s knowledge, have allocated Psychology positions to specific deployed units (e.g. Aviation, SAS), and routinely deploy full-time uniformed psychologists to operations. Navy and Air Force have deployed Psychiatrists, Medical, Nursing, and Psychology Officers with specific fleet units or on specific operations. These deployments typically involve officers with varying levels of mental health training. If the current situation prevails, the quality of mental health support services provided is likely to remain patchy and dependent on individual training and experience. The better alternative is to introduce common training which is evidence-based.

Demand for deployable mental health support Provision of MHS ought to be demand driven, not supply driven, and provided via well –trained MHS teams that have demonstrated value in force preservation. Future demand for operational mental health support is likely to be influenced by the following factors: (1) the prevalence of both diagnosed and undiagnosed mental disorders in the ADF(7), particularly among deployed personnel or those eligible for deployment; (2) the adequacy with which ADF personnel are psychologically prepared for specific high risk tasks and operations, (3) the cumulative effect of exposure to previous high risk operations(7); and (4) recent casualty rates, current danger levels, and the current frequency of combat and expected incidence of potentially traumatic events.

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Table 1. Defined mental health support capabilities. Type of mental health service

Defined and deployable capability

Non deployed mental health service

Maritime

Land

Garrison

1. Wellbeing and resilience training (partly defined)

1. Wellbeing and resilience training (partly defined)

1. Wellbeing and resilience training;

2. Resilience training for particular high risk tasks

2. Resilience training for particular high risk tasks

3. Alcohol, tobacco and other drugs program.

Early detection

Return to Australia Psychological Screening (RtAPS)

Return to Australia Psychological Screening (RtAPS)

Post Operational Psychological Screening (POPS)

Critical incident or potentially traumatic events

Critical Incident Mental Health Support (CIMHS)

Critical Incident Mental Health Support (CIMHS)

Critical Incident Mental Health Support (CIMHS)

Human factors and performance (e.g. fatigue management)

nd

nd

nd

Acute psychological casualty triage

nd

nd

Available via regional health services

Clinical treatment for acute distress (proximal and immediate )

nd

nd

Available via regional health services

Rehabilitation

na

na

Available via regional health and rehabilitation services

Preventative

2. Suicide awareness and prevention;

Notes: nd: specific capability not yet defined; na: not applicable to operations.

Mental health support services range from prevention through to detection and treatment, and long-term management. Although not all of these services may be required for deployment, each warrants consideration during operational planning. Mental health services that can support operations are broadly classified in Table 1. Alternatively, mental health support can be seen as part of a broader range of psychological support to the ADF that involves the support functions currently provided by garrison psychology and garrison mental health services. Murphy and Cohn(8) outline a three pillar support model that differentiates (1) organisational health and effectiveness; and (2) performance enhancement; from (3) psychological health and readiness, at an individual level. Mental health support to individuals is usually included within the last category. Because mental health support is construed as psychological support, there is the risk that other relevant support disciplines (medical, psychiatry, mental health nursing, ADF civilians) will be excluded. These supplementary supports will be needed in response to extreme events where psychiatric and psychological casualties may reach 30% or more of the deployed force. Outside the military, multidisciplinary teams are already the standard for the delivery of public funded mental health services(9). Within the military, health support planning can be enhanced by developing cost-conscious support plans with full anticipation of surge scenarios that utilise all appropriately trained health personnel.

ADF mental health personnel What mental health personnel resources are currently available for deployment? It appears that full-time uniformed assets are often the first and only personnel deployed by both Joint Operations Command and Joint Health Command in both joint and single service operations. Even though other lower cost, personnel elements may be available at short notice. Land Command has a deployable full-time psychology asset (1 Psychology Unit), primarily geared to deploy Army Psychologists to Land Command areas of operations. This unit

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has approximately 10 full-time Army Psychologist positions (Officers) and 9 full-time Army Psychology Examiners [Personal communication with DMHPR staff] and typically deploys these personnel for short periods to land based operations. These teams may be supplemented by part-time uniformed elements namely, Army Reserve Psychology Officers, Army Reserve Chaplains, and Army Reserve Psychology Examiners. Navy has a deployable mental health unit intended specifically for the maritime environment. The Navy Reserve Psychology (NRP) branch currently consists of approximately 19 Active Reserve and 15 Standby Navy Psychology officers [Personal communication with Assistant Director-NRP]. In addition, one senior Active Reserve Nursing Officer with extensive civilian training and experience in public mental health nursing is routinely utilised for deployments with this unit. However, maintaining deployment readiness of sufficient personnel to respond to all requests for assistance has been challenging because of inadequate specialised training, travel resources or unit administration support. NRP receive administration support from Navy Health but unlike 1 Psych Unit, they are a part-time uniformed unit with no home base, no full-time positions, no equivalent positions to Army Psychology Examiners, and no administration support positions other than the Assistant Director, who provides a range of administration and management roles. The last review of the NRP branch identified deployment to maritime operations as a core NRP function(10)0. While this review was accepted, no subsequent action was taken by Navy to formalise its recommendations. This prompted the NRP branch to set its own priorities among the various support requests from both garrison and operational sources. The unit currently responds to all Navy requests for CIMHS and RtAPS assistance, and rarely needs supplementation from other uniformed elements. Responses usually involve small teams of NRP personnel who deploy to sea during return passage from

41

operations. NRP also provide Navy with support for within garrison psychology case work services and Post Operational Psychological Screening (POPS). Army have approximately 100 Army Reserve (ARES) Psychology Officers and 100 ARES Psychology Examiner positions. About 40% of these are thought to be filled by Active Reserves [Personal communication with DMHPR staff] many of whom have been trained in RtAPs, POPS and CIMHS. ARES personnel therefore represent a potentially large deployable asset and surge capacity when needed. Other potentially suitable personnel include an unknown number of uniformed health personnel with specialist mental health training. Air Force has an indeterminate number of fulltime uniformed Health Officers, and Specialist Reserve Health Officers, some with extensive mental health training. This includes nursing officers, psychologists and psychiatrists, who could when released and prepared, participate in delivering deployable mental health support capabilities. Navy also have uniformed Psychiatrists, Medical Officers and Nursing Officers with suitable MHS training and experience. . All three services utilise contracted civilian Medical Officers and Navy and Airforce also employ civilian Psychologists. Other civilian allied health professionals, drug and alcohol counsellors, and social workers, are employed by the ADF, all with varying levels of mental health training. Some of these non-psychology personnel are highly trained in mental health assessments and treatments and could be released for mental health support deployments. The design of personnel records however, does not yet permit the identification of all full-time, part-time, and APS civilian personnel with suitable psychology, psychiatry, or other mental health qualifications and training. Therefore the ADF may already have a much larger but unquantified supply of suitable personnel with mental health training, possibly from Psychiatry, Medical, Nursing and Psychology disciplines. Most of these other disciplines are not currently utilised in existing organisational structures.

Limitations of current organisations Table 2 shows some of the limitations of current organisations. A common limitation is the failure to utilise all available mental health personnel in multidisciplinary teams (Psychiatrists, Psychologists, Medical and Nursing officers) that are now the standard for civilian public funded mental health treatment and care(9). Furthermore, the primary existing organisation

(1-Psych) that provides the bulk of deployed mental health support to Joint Health Command operates on a high cost model using mostly full-time uniformed personnel for short deployments. In addition, neither NRP nor 1-Psych are sufficiently prepared to operate in all three battle spaces, neither organisation has surge capacity plans in place to respond to worst case scenarios where high numbers of acute psychological casualties are expected in both Maritime and Land Command environments.

Alternative organisations Alternative ways to organise the deployment of mental health support capabilities are shown within Table 3. All options utilise the range of mental health personnel available. Options 2 and 3 provide the same capability as Option 1, but by using a lower cost workforce mix, but which may require a redistribution of resources across the three services to develop and sustain. Option 3 has the potential to be the most cost-efficient by combining resources at one site, while retaining Land Command and Maritime specialisations. The volunteers needed could be recruited by advertising new deployment opportunities to known personnel groups, bypassing the need to upgrade personnel records prior to identifying suitable personnel. Full-time uniformed personnel need not be sidelined by any reorganisation which transfers the primary responsibility for deployable mental health support to part-time and civilian personnel. There are other important garrison and operational mental health support requirements that are best suited to full-time uniformed elements. For instance, long deployments to mental health support positions within special operations units (e.g. Aviation, Clearance Divers, and SAS) require fulltime uniformed personnel or part-time uniformed members on long rotations or continuous full-time service. In addition, full-time uniformed personnel are needed to develop and test capabilities and train and sustain sufficient part-time uniformed and civilian elements to maintain high standards and to enable cost effective delivery of defined capabilities. Furthermore, since leadership of deployed mental health support teams is best selected on the basis of individual preparation, skills, qualifications and experience, full-time uniformed personnel could ensure leadership gaps can be covered when necessary.

Potential savings Savings are anticipated through a reduction in the total number of permanent full-time uniformed psychology and mental health personnel needed by the ADF. A smaller number

Table 2. Mental health support personnel in the ADF. Unit or personnel source

Primary deployed environment

Dedicated administration, logistics, and training support

Core personnel

Current surge plan

ARA 1 Psychology Unit

Land

Yes

Full-time

No

Navy Reserve Psychology

Maritime

Partial through Navy Health

Part-time

No

Air Force Health Officers and Specialist Reserve Officers

Land (air bases)

Yes

Full-time and Part-time

No

Other uniformed mental health specialists

Both

No

Full-time and Part-time

No

Other Defence civilian fulltime and part-time mental health specialists

Both (Voluntary only due to employment conditions)

No

APS civilian full-time and part-time

No

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of such positions could be retained to coordinate the training and preparation of all other personnel elements. Full-time ADF civilians represent a moderate saving of 20% or more, over equivalent rank full-time uniformed personnel. However, ADF Reserves represent a greater cost-benefit at a five to ten-fold saving, depending on how training and coordination costs are managed. This is because 15 ADF Reserve personnel serving 20 or more days each, can provide the same annual service coverage (48 weeks) as one full-time uniformed member, at nearly the same cost. The savings mostly come from retaining fewer full-time personnel for mental health support contingencies. One full-time member could be used to train and prepare up to 20 part-time personnel, to provide a simultaneous deployable capability of 20 personnel for 4 weeks duration, which equates to the ongoing costs of only two full-time personnel. Under the current system, the 20 personnel deployed would most likely be full-time, sometimes supplemented by part-time members. This is about ten times the cost of dedicating this role to parttime personnel elements. Part time MHS staff could be trained and organised, in a cost-conscious manner, as first responders for pre-defined

deployable health support capabilities. Since many personnel from several disciplines are already available to do this work, such a system could be established with savings generated through natural attrition of full-time uniformed personnel. In times of low demand for deployed support, a base unit could be tasked to develop new capabilities and develop surge plans for extreme events. Candidates from other disciplines with sufficient background mental health training would be attracted to MHS teams which provided sound evidence-based training and this would improve the opportunities to raise, train and sustain multidisciplinary MHS teams across the ADF.

Counter arguments Some stakeholders will favour the status quo and will resist change, no matter what potential benefits could accrue in terms of improved health support capability. The aim of this paper has not been to advance a particular alternative model, but to bring the organisation of deployable mental health support capabilities to the reform agenda. How can these capabilities be best organised in the ADF? Whilst it currently makes sense to give deployment priority to the best prepared personnel elements (currently full-time uniformed Army Psychology), it is not logical to avoid planning for a surge capacity, or to ignore

Table 3. Alternative ways to organise deployable mental health support. Organisation option

Advantages

Disadvantages

Option 1.

1. Strengthens an existing deployable unit with existing infrastructure and resources.

1. The focus remains on Land Command deployments by full-time uniformed personnel.

Set lead agency as 1 Psych Unit, supplemented by a surge plan involving other part-time and full-time volunteer s (ARES, NRP, Reserve Psychiatrists, Health Officers, Medical and Nursing officers, and Defence civilians)

2. Over time, maritime and Air Force sub-units could be developed. 3. Utilises all available mental health trained personnel.

2. Personnel receive little or no training for maritime deployments and may become inoperative at sea through accidents or sea sickness. 3. The high cost is inconsistent with strategic and budget reform principles. 4. The short-term nature of typical deployments indicates suitability for part-time personnel. 5. Command and control remains unclear in Maritime environments.

Option 2. Establish NRP as the lead agency for maritime deployments. Retain 1 Psych Unit as the lead agency for all Land Command and Air Force deployments. Supplement both units with all other mental health personnel on a voluntary basis.

Option 3. Create a new tri-service organisation (e.g. 1 Mental Health Support Unit). Develop two specialised divisions: (a) Land Command and Air Force; and (b) Maritime. Transfer both capabilities to part-time elements (ARES and NRP as core agencies) supplemented by fulltime posted positions and positions for other volunteers, both full-time uniformed and civilian.

1. Solves the problem of competition between Land Command, Air Force and Maritime for the same mental health support resources. 2. Command and control in Maritime and Land Command environments is unambiguous, and service specialisations are retained.

1. Replicates an existing unit without identifying budget savings. 2. Does not address the reform goal of transferring deployment capabilities from costly full-time elements to part-time personnel elements. 3. New resources would be required for parttime personnel to maintain similar standards to full-time personnel.

1. Solves the problem of competition between Land Command, Air Force and Maritime for the same mental health support resources. 2. Command and control in Maritime and Land Command environments is unambiguous.

1. A redistribution of resources may be required to enable the new part-time units, supported by full-time personnel (uniformed and nonuniformed) to develop and maintain similar standards to full-time uniformed personnel.

3. Greater efficiency in the provision of infrastructure and training resources to both units. 4. Costs could be shared among the three services or met by JHC or JOC. 5. When not deployed or training for deployment, volunteers could continue to support garrison mental health services, and deliver preventative mental health support services and capabilities. 6. Savings generated through a reduction of 50% or more in full-time uniformed positions.

ADF Health | Vol 12 No. 1 | 2011

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more cost-effective utilisation of personnel elements, particularly when most mental health support deployments are typically of short duration, and the effectiveness of multidisciplinary teams is so well accepted in modern civilian practice.

Conclusions This paper illustrates some examples of how strategic reform principles can be applied to the development of ADF mental health support capabilities. 1-Psych unit currently have the garrison location and the resources necessary to provide this range of services in a sustainable way, but at high cost and with no known surge capacity plan. NRP on the other hand have demonstrated how short duration mental health support can be provided as a core capability of a Reserve element, on a frugal budget with little direct involvement of full-time uniformed personnel. Neither unit currently makes best and cost effective use of all the available ADF mental health trained personnel. A way forward is suggested by considering the three options shown in Table 3. Each represents increasing change consistent with Strategic and budget Reform. Although Option 3 represents the most change, it also promises the most cost effective base for the development of genuine tri-service and standardised mental health support capabilities. However these deployable mental health assets are organised, it will be important to give each a strong multidisciplinary focus to ensure the best mental health services are applied to force preservation when encountering high incidence of acute psychological casualties. JOC and JHC should be encouraged to further investigate the cost-benefits of a reformed organisation for deploying mental health services as outlined in Table 3.By doing so they

will comply with the requirement for ongoing cost-conscious strategic reform of health services in the ADF.

References 1.

Hodson SE, Moore L, McGrogan J. The mental health reform process (Dunt report): A support system for ADF personnel. ADF Health 2009; 10(1): 20-22. 2. Department of Defence. Defending Australia in the Asia Pacific Century: Force 2030. Defence White Paper, Canberra: Australian Government Publishing Service, 2009: 107-117. <http://www.defence.gov.au/ publications/reformBooklet.pdf viewed 16 August 2011> viewed 16 Aug 11 3. Department of Defence. Defence Budget Audit. Executive Summary, 2009: Accessed 5 November 2009 at http://www.defence.gov.au 4. Dunt, D. Review of Mental Health Care in the ADF and Transition through Discharge. Canberra: Department of Defence, 2009. Accessed 5 November 2009 at http://minister.dva.gov.au/media_releases/2009/ may/va031.pdf 5. Department of Defence. Defence Instructions (General), DIG PERS 16-25, Amendment number 1, Critical Incident Mental Health Support in Defence. Canberra: Department of Defence, 2008. 6. Cohn A, Hodson SE, Crane M. Resilience training in the Australian Defence Force. InPsych 2010: April. 7. Sareen J, Belik S, Afifi TO, Asmundson GJG, Cox B, Stein MB. Canadian military personnelâ&#x20AC;&#x2122;s population attributable fractions of mental disorders and mental health service use associated with combat and peacekeeping operations. American J Public Health 2008; 98(12): 2191-2198. 8. Murphy P, Cohn A. Mental health innovations in the Australian Defence Force. Journal of Occupational Health and Safety Australia New Zealand 2008; 24(6): 541-552. 9. Thornicroft G, Tansella M. Components of a modern mental health service: a pragmatic balance of community and hospital care. Brit J Psychiatry 2004; 185: 283-290. 10. Latimer S. Review of Australian Naval Reserve Psychology Branch. Canberra: Department of Defence, Unpublished Submission to NAVSYSCOM, 2001.

public health

Townsville field training area health assessment Lieutenant Ben M. Brumpton, Captain Brady A. McPherson, Major Stephen P. Frances, Major Timothy J.J. Inglis, Colonel Bradley J. McCall

Abstract

Ben M. Brumpton, MPH, LT, MEHA, Environmental Health Officer, Environmental Health Platoon, 2nd Health Support Battalion, Gallipoli Barracks, Enoggera, QLD 4051, Australia Brady A. McPherson, MPH, CAPT, Environmental Health Officer, Environmental Health Platoon, 2nd Health Support Battalion, Gallipoli Barracks, Enoggera, QLD 4051, Australia* Stephen P. Frances, MScAgr, PhD, MAJ, Entomologist, Australian Army Malaria Institute, Gallipoli Barracks, Enoggera, QLD 4051, Australia Timothy J.J. Inglis, BM, DM, PhD, FRCPath, FRCPA, FFSRCPA, FACTM, FRGS, DTM&H, MAJ, FRCPA, Medical Microbiologist, 1st Health Support Battalion Environmental Health, Holsworthy Barracks, NSW 2173, Australia Bradley J. McCall, MB BS, MPH, COL, FAFPHM, Director of Clinical Services, 2nd Health Support Battalion Environmental Health, Gallipoli Barracks, Enoggera, QLD 4051, Australia *Corresponding author: Environmental Health Officer, Environmental Health Platoon, 2nd Health Support Battalion Environmental Health, Gallipoli Barracks, Weary Dunlop Dr, Enoggera, QLD 4051, Australia, Ph: (07) 33324698, Fax: (07) 33324672, Email: brady.mcpherson@defence. gov.au

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The Townsville Field Training Area (TFTA) which is located 50 km west of Townsville, northern Queensland, has a number of important disease and safety threats to the health of military personnel. Since its establishment the training area has not been thoroughly assessed for environmental health risks. In May 2010 a Health Assessment Team (HAT) engaged in a comprehensive sweep of health threats across the training area. This article includes information on the environment, disease threats, range hazards, local health infrastructure, and utilities such as water and sanitation. A risk assessment of the health threats identified in the TFTA and their assigned risk was conducted. Major risks include motor vehicle accidents, heat-related injuries and vector-borne diseases. Environmental health support can appropriately identify, assess and manage possible risks associated with the TFTA. These efforts will support commandersâ&#x20AC;&#x2122; objectives to achieve the maximum conservation of manpower by preventing disease and nonbattle injuries.

Introduction The Townsville Field Training Area (TFTA) is located near Townsville on the Queensland coast, 1335 km north of Brisbane, Australia. The Townsville area contains a wide range of terrain and has a frontage of long open beaches bordering the east coast. Topography includes mudflats, mangroves, tidal creeks, marine couch plains, savannah forest amid steep rugged ranges which in some places are rocky and heavily timbered. The TFTA crosses Townsville City Council and Charters Towers Regional Council and covers an area of 2,300 km2. The topography within the TFTA is dominated by open sclerophyll forests which feature in the west, rugged ranges and wet rainforest to the north-east, and gentle undulating plains to the south. The TFTA has a tropical climate but, due to its geographical location, rainfall is relatively low. The winter months are dominated by south-east trade winds and mostly fine weather. The summer months bring a hot and humid climate with thunderstorms starting in late October or November. Tropical cyclones are rare, effecting Townsville on average once every 20 years. The aim of this report is to provide

45

in the TFTA, however potable bore water supplies are not seen as a high risk. A risk assessment table of the water and food-borne disease and causative agents on the TFTA can be found in Table 1. Table 1. TFTA water and food borne diseases risk assessment. Water and food borne diseases

Open sclerophyll forests in the TFTA.

personnel, commanders and formation health planners with information about the potential environmental health risks that exist within the TFTA and in the Townsville region.

Methods A combined 1st Health Support Battalion and 2nd Health Support Battalion, Hazard Assessment Team (HAT) conducted a hazard assessment of the TFTA during the period 12 – 21 May 2010. The HAT conducted the assessment using a number of methods. Firstly, a review of available epidemiological data was conducted prior to deployment in order to collate background data and in some cases tailor the field survey. The field survey consisted of site inspections, environmental sampling and analysis, mosquito trapping, as well as liaison visits to Range Control, Queensland Health, Defence Support Group (DSG) and local health facilities. Confirmatory testing was conducted of water and mosquito samples at accredited laboratories. Finally an adapted military risk framework was used to assess the level of risk associated with potential hazards identified.(1)

Disease threats The following disease risks have been identified within both the TFTA and the Townsville City Council and adjacent shires. The potential exists for the spread and introduction of these diseases into the TFTA through contact with the civilian community, family members and other military personnel.

Water and food borne diseases Each year water and food-borne disease occurs from contaminated water and food sources and includes amoebic dysentery, Escherichia coli infections, Bacillus cereus food poisoning, campylobacteriosis, cryptosporidiosis, giardiasis, hepatitis A, salmonellosis and shigellosis. In Townsville Shire there was a number of salmonellosis reported, 826 cases in 2005 to 2010 and an average annual incidence of 112.48 per 100 000 during the period 2003 – 2007.(2-3) Gastrointestinal disease such as E. coli and Salmonella are quite common in the tropics and many non-potable water sources tested positive for E. coli, presenting a hazard in the TFTA. While tests for Cryptosporidium on all potable water sources were negative; outbreaks have been associated with drinking water (surface water) and recreational use of water. Waterways and nonpotable water sources are a potential hazard for Cryptosporidium

Hazard

Likelihood

Impact

Risk

Amoebic Dysentery

Rare

Disruptive

Low

Bacillus cereus food poisoning

Rare

Disruptive

Low

Campylobacter spp. Enteritis

Rare

Disruptive

Low

Cryptosporidium

Rare

Disruptive

Low

E. coli

Occasional

Disruptive

Medium

Giardia intestinallis

Rare

Disruptive

Low

Hepatitis A

Highly Improbable

Serious

Low

Salmonella

Occasional

Serious

Medium

Shigella

Rare

Disruptive

Low

Vector borne diseases Several vector-borne diseases are endemic and notifiable in north Queensland. These include, but are not limited to, the arboviruses: Barmah Forest (BF), dengue, kunjin, Murray Valley Encephalitis (MVE) and Ross River (RR) as well as Orientia tsutsugamushi the cause of scrub typhus. Historical data for vector-borne diseases in Townsville Shire is in Table 2. Table 2. Historical data for vector borne diseases in Townsville Shire.(2-3) Historical data of vector borne disease Disease

2003 – 2007

2005 – 2010

Barmah Forest

474

497

Dengue

158

176

Malaria

79

55

Rickettsial infections

<30

–

Ross River Virus

1062

1177

The mosquito Culex annulirostris is the primary vector of a number of Australian arboviruses and was collected throughout the TFTA. Cx. annulirostris is capable of transmitting BF virus, RR and MVE indicating that these viruses may be circulating in the TFTA at the time of these surveys. Reservoirs of kunjin were identified in the TFTA. No Aedes aegypti, the vector of dengue, were collected during mosquito surveillance of the TFTA. However a number of large outbreaks of dengue fever have occurred in northern Queensland in recent years. Despite cases of malaria being reported in the Townsville Shire, there has been no recorded local transmission. Anopheles sp. (primarily Anopheles annulipes) was collected during mosquito surveillance of the TFTA. Therefore the training area is theoretically receptive to malaria imported by overseas troops. However, the main vector of malaria in the southwest Pacific region is Anopheles farauti and this species has never been collected at TFTA.(4) A risk assessment table of the vectorborne disease associated with TFTA can be found in Table 3.

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Table 3. TFTA vector borne diseases risk assessment. Vector borne diseases

Environmental threats include dangerous fauna, flora, heat, cold, solar radiation, fire and severe weather.

Hazard

Likelihood

Impact

Risk

Barmah Forest

Occasional

Disruptive

Medium

Dengue

Highly Improbable

Serious

Low

Kunjin

Rare

Disruptive

Low

Malaria

Highly Improbable

Critical

Low

Murray Valley Encephalitis Virus

Rare

Catastrophic

Medium

Hazard

Likelihood

Impact

Risk

Rickettsial infections

Rare

Serious

Medium

Brucellosis

Highly Improbable

Serious

Low

Ross River Virus (RR)

Occasional

Disruptive

Medium

Leptospirosis

Highly Improbable

Serious

Low

Ornithosis

Highly Improbable

Minor

Very Low

Q Fever

Highly Improbable

Serious

Low

Hookworm disease

Rare

Disruptive

Low

Meliodosis

Highly Improbable

Serious

Low

Tetanus

Highly Improbable

Serious

Low

Influenza

Occasional

Disruptive

Medium

Legionella

Rare

Disruptive

Low

Zoonotic diseases TFTA is a suitable environment for several disease-causing agents that can be transmitted between humans and animals. The historical data for zoonotic disease is in Table 4. Table 4. Historical data for zoonotic diseases in Townsville Shire. (2-3) Historical data of zoonotic disease Disease

2003 – 2007

2005 – 2010

Table 5. TFTA zoonotic, soil and airborne disease risk assessment. Zoonotic disease

Soil diseases

Airborne diseases

Brucellosis

11

<5

Leptospirosis

10

9

Environmental threats Environmental threats include dangerous fauna, flora, heat, cold, solar radiation, fire and severe weather. Commanders and individuals must have a thorough understanding of the range of environmental threats that can be encountered whilst on the training area to appropriately engage in preventative measures.

Ornithosis

<5

<5

Q Fever

46

47

Reservoirs (cattle, goats and dogs) of brucellosis are present in the TFTA. However, the likelihood of coming in contact with the disease is highly improbable, Table 5. Leptospirosis is active at low levels in Townsville Shire. Very low numbers of ornithosis cases have also been recorded in the Townsville Shire however reservoirs (birds) for Chlamydiphila psittacosis were observed in the TFTA. There were also a low number of Q Fever cases in the Townsville Shire and potential animal reservoirs (cattle, sheep and goats) were identified in the TFTA.

Soil disease Soil diseases such as hookworm and tetanus are present in TFTA. Spores and larvae of these diseases can remain viable in the soil for years after contamination.(5) However, this risk is substantially reduced due to the Australian Defence Force vaccination protocol, Table 5. Melioidosis is also present at low levels in the Townsville Shire.

Airborne diseases Airborne diseases including influenza have the potential to spread rapidly through soldiers who are working in close living conditions on operations. There have been 813 confirmed cases of influenza in the Townsville Shire in the period 2003 to 2007 and an average annual incidence rate of 73.75 per 100,000 during the period 2003 – 2007.(2-3) A less significant airborne risk in TFTA is Legionella spp., Table 5. There has been one case of Legionellosis in the Townsville Shire in the period 2005 to 2010 and an average annual incidence rate of 0.4 per 100,000 during the period 2003 – 2007.(2-3) Legionella was identified in previous environmental monitoring of the vehicle hygiene facility at TFTA by DSG.

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Dangerous fauna – Vertebrates TFTA is the natural habitat for many vertebrates including snakes, toads, pigs and goannas, Table 6. Several snake bites occur each year during activities on the TFTA and dangerous species include Pseudechis australis (King Brown), Pseudonaja textilis (Eastern Brown), and Oxyuranus scutellatus (Taipan). Cane toads, pigs and goannas are of little danger to humans unless handled inappropriately. No dangerous incidences of these vertebrates have been recorded in the TFTA. However, all are commonly observed in the TFTA and can be easily avoided.

Dangerous fauna – Invertebrates Injuries from invertebrates not only present short term local pain and discomfort but they can also be responsible for asphyxiation and death. Incidences of spider bites have been recorded and it is important that all members follow simple control measures to avoid contact with invertebrates. A list of dangerous invertebrates and associated risk is assed in Table 6.

Dangerous flora Plants present a health risk to soldiers via two different mechanisms. Many plants can be poisonous if eaten and several are contact irritants that can cause skin irritations and lacerations from contact with sharp hairs or spikes of the plant. The training area is predominantly open grasslands and easily navigated. However, creek lines and high rain fall areas of the range in the north-east contain a wide diversity of dangerous flora, Table 6.

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Table 6. TFTA dangerous fauna and flora risk assessment. Dangerous fauna – Vertebrates Hazard

Likelihood

Impact

Risk

Snake

Occasional

Serious

Medium

Cane Toad

Highly Improbable

Minor

Very Low

radiation may result in burns, particularly to the skin and eyes, and the formation of skin cancers. Australia has the highest incidence of solar induced skin cancer in the world and it is the most common form of cancer affecting Australians in all age groups.

Feral Pig

Highly Improbable

Serious

Low

Fire

Goanna

Highly Improbable

Minor

Very Low

The TFTA frequently experiences wildfires, managed fires and accidental bush fires. These can be ignited by lightning strikes during thunder storms or by spot fires caused by people. Fires such as these have been responsible for the lost of equipment, wildlife and present a significant threat to human life in the training area, Table 7.

Dangerous fauna – Invertebrates Centipede

Rare

Disruptive

Very Low

Green Tree Ant

Rare

Disruptive

Very Low

Paper Wasps

Rare

Disruptive

Very Low

Ticks & Mites

Occasional

Disruptive

Low

Spiders

Rare

Serious

Low

Scorpion

Highly Improbable

Minor

Very Low

Whiplash Rove Beetles

Highly Improbable

Minor

Very Low

Dangerous flora Consuming Dangerous Flora

Highly Improbable

Serious

Low

Contact of Dangerous Flora

Rare

Minor

Low

Cold related injuries Although the TFTA is located in the northern tropical regions of Australia, due to its significant elevation above sea level (approximately 600 m) cold weather injuries can still occur, Table 7. Throughout the winter months of May - August preventive measure should be taken, Figure 1.

Severe weather events Tropical cyclones are rare, affecting Townsville on average once every 20 years. However severe storms and weather events from late October until April are sporadic. While most deaths from severe weather events occur as a result of drowning, many lives have been lost in Australia due to collapsing buildings or flying debris which can become lethal in high winds, Table 7. Table 7. TFTA cold related injuries, heat related injuries, solar radiation, fire, and severe weather events risk assessment. Cold related injuries Hazard

Likelihood

Impact

Risk

Cold related injuries

Highly Improbable

Serious

Low

Occasional

Catastrophic

Substantial

Likely

Minor

Low

Highly Improbable

Serious

Low

Highly Improbable

Disruptive

Low

Heat related injuries Heat related injuries Solar radiation Solar radiation Fire Fire Severe weather events Severe weather events

Other range hazards

Figure 1. Monthly temperatures TFTA Woolshed 1998 - 2010.

Heat related injuries Within the military environment, heat casualties, including deaths, occur in units operating in hot climatic conditions. The TFTA (particularly between the months October - March) will reach temperatures which will cause injury if appropriate action is not taken. A number of factors contribute to heat stress. These include air temperature, humidity, air movement, water consumption, physical activity and acclimatisation. Little can be done about the climatic conditions of an operational environment; therefore prevention of heat injury is centered on control of the latter three factors. Failure to follow preventive measures during operations in hot environments will result in large numbers of heat casualties and a unit’s inability to train effectively, Table 7.

Solar radiation Solar radiation, in the form of Ultra Violet radiation (UV) in sunlight, poses a low health risk, Table 7. Over exposure to UV

Along with environmental threats, TFTA has many hazards caused by the built environment. Unlike environmental threats, these hazards generally occur on specific areas or pathways in the training area. These include asbestos, mining and land contamination, unexploded ordinance, and motor vehicle accidents.

Asbestos Asbestos materials are present in the TFTA, the majority being found in building materials such as wall sheeting. In general, asbestos products pose no harm if they are in good condition and are left alone by exercise participants, Table 8. If asbestos products are in poor condition and are disturbed, asbestos fibres may become airborne and be inhaled by humans. At sufficient exposure levels asbestos fibres may cause diseases such as cancer, asbestosis and mesothelioma. Facilities identified to have asbestos products in poor condition have been cordoned off and are out-of-bounds to exercise participants. An asbestos register is maintained by DSG and is updated regularly. Units entering the training area should consult the DEMS asbestos register for up-to-date information and risk levels.

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Mining and contaminated land The land that now comprises the TFTA has been the home of many mining and agricultural operations in the past. Gold, silver, copper and uranium have all been mined within the TFTA (or adjacent lands). There are numerous abandoned mines, abandoned landfills, mining shafts and disused cattle dips present within the TFTA, the majority of which have been designated as out-of-bounds to all personnel. These areas pose a safety hazard to anyone venturing too close and should be avoided, Table 8. Methods used in the mining and agricultural process may also have contaminated local soils and ground water with heavy metals (e.g. Cyanide and Arsenic).

blind corners, pot holes, dips and washouts that drivers need to approach with caution. Anyone travelling by vehicle through the training area must abide to the speed limit on the range (45kph) and drive according to the prevailing conditions both road and weather. Table 8. TFTA asbestos, mining and contaminated land, unexploded ordinance, and motor vehicle accidents risk assessment. Asbestos Hazard

Likelihood

Impact

Risk

Asbestos

Highly Improbable

Serious

Low

Highly Improbable

Serious

Low

Highly Improbable

Serious

Low

Occasional

Catastrophic Substantial

Mining and contaminated land Injuries due to previous mining and contaminated land Unexploded ordinance Unexploded ordinance Motor vehicle accidents Motor vehicle accidents

Water treatment plants The TFTA has three points of distribution for potable water. The quality of the water varied over the three sites during the assessment. Chlorine levels at all three water supply locations fluctuated greatly between 0 and 5 mg/L during the period September 2009 to February 2010 (Figure 2). Chlorine levels below 2 mg/L at the point of production are not suitable for consumption by personnel and drops in chlorine levels were reflected in high levels of microbiological activity (Figure 3). Water samples were however negative for E. coli at all three of the water points. Environmental health monitoring of water should be conducted prior to and during exercises to ensure chlorine levels are a minimum of 2 mg/L at the point of production. Chlorine dosing of bulk water from the distribution point must occur if chlorine levels do not reach the required standard.

TFTA hazardous site, Argentine smelter.

Unexploded ordinance

Raw bore water tests conducted by DSG between 2001 and 2008 recorded high levels of lead and uranium in ground water. The tests conducted during this survey however, found these parameters at acceptable levels. Reverse osmosis water treatment plants are installed at most water points to protect against any

Unexploded ordinance (UXO) is prevalent throughout the TFTA. UXOs are a result of live firing activities and personnel should be wary of UXOs in all sectors, Table 8. If personnel encounter a suspected UXO, they should not disturb it but report its location to range control.

Motor vehicle accidents According to range control records, motor vehicle accidents are the most prevalent of incidents in the TFTA, Table 8. Several motor vehicle accidents have occurred in the TFTA including head-on collisions, run-off-road collisions, rear-end collisions, side collisions, and rollovers. These have been due to driver error, speeding, reckless driving, fatigue and poor road conditions. Throughout the range, road conditions vary from good to poor and with high use during exercises the roads will deteriorate quickly. There are also many steep hills, ADF Health | Vol 12 No. 1 | 2011

Figure 2. Free chlorine levels (mg/L) across TFTA during the period September 2009 â&#x20AC;&#x201C; February 2010.

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Although this study did not cover occupational assessment the highest risk to defence personnel was from motor vehicle accidents. Motor vehicle accidents are a substantial risk to military personnel and must be treated as such. The road system within the TFTA is variable depending on the time of year and recent use. There have been numerous motor vehicle accidents on the range in recent years with several accidents occurring whilst the survey team was present in the training area. All drivers must exercise caution and comply with speed limits as roads are subject to flooding during the wet season (November to April) and rapid deterioration during major exercises. Figure 3. Camp 1, 2009/2010 â&#x20AC;&#x201C; Free chlorine (mg/L) versus bacterial quantity (CFU/100 ml).

possible contamination. These plants successfully remove heavy metals, with treated water samples showing levels below the guidelines. It is recommended that routine monitoring is continued to ensure plants are working effectively. As some water points do not have reverse osmosis water treatment plants, regular monitoring needs to be conducted. If results indicate signs of contamination, use of this water should be discontinued until such time as results improve or a reverse osmosis water treatment plant is installed. At the time of this report, water at the three potable water points was not suitable for distribution due to low chlorine levels. Water at the potable water points was however suitable for direct consumption. Many non-potable water sources are located around TFTA. These are primarily used for showers and latrines (SALs). These sources must not be consumed or used for activities like the brushing of teeth. Hand wash facilities are provided in the SAL. However, it is recommended that anti-bacterial hand washes are used before the preparation of food and drinks. All non-potable water sources tested positive for total bacteria and many were also positive for faecal coliforms. Non-potable water is not suitable for human consumption.

Waste treatment plants The toilet facilities are provided by Defence Support Group (DSG). However, individual units are responsible for daily cleaning. The facilities do not have consumables such as soap, hand wash and paper towel. All units are responsible for the provision of these consumables. Anti-bacterial hand wash is recommended as all SAL water is non-potable. Waste water treatment types varied across the SAL. Treatment types included sediment ponds, adsorption trenches and biocycle treatment. Outputs were monitored by DSG and indicated high levels of faecal coliforms. It is important that these treatment areas are avoided to prevent the spread of infectious pathogens.

Discussion The climate at TFTA is hot and humid which presents a substantial risk of heat related illness. Commanders must appreciate this risk and employ appropriate risk reduction measures which include acclimatisation. The climate also facilitates the proliferation of mosquitoes, ticks and mites which are vectors of many serious diseases. The survey team confirmed the presence of the RR, BF and MVE mosquito vectors. This finding enforces the need for strict compliance with vector control measures and the requirement for environmental health support for all personnel deploying into the TFTA.

The close environment of military training also provides opportunities for outbreaks of communicable diseases, particularly food and water borne diseases and those relating to personal hygiene. It is imperative that commanders enforce safe food and water practices and deploy with adequate hygiene supplies such as soap and handtowels. The TFTA also harbours a variety of flora and fauna which can cause serious illness or even death to troops in the field. Military personnel, in particular medical staff, should be familiar with the main features of these hazardous flora and fauna and all personnel must be aware of the first aid principles required to treat personnel who come into contact with them. There are a number of other safety hazards in the TFTA. These include UXOs, disused mining shafts, cattle dips, as well as fire and other severe weather events. Personnel need to be vigilant of their own safety and report any safety hazards to range control. It is imperative that commanders consult environmental health support in order to appropriately prepare for the possible risks associated with the TFTA and therefore ensure the maximum conservation of manpower by preventing disease and non-battle injuries.

References 1

Australian Army. Army technical instruction 01/2007: Military risk management. 14 January 2007. http://intranet.defence.gov.au/ DRMS/uR3816/R3392593.pdf (accessed May 2010).

2 Queensland Health. Communicable Diseases Branch. Valid notifications Townsville LGA 2005-2010. 3

Queensland Health. Notifiable condition counts and rates 20032007. 10 Feb 2010. http://www.health.qld.gov.au/ph/Documents/ cdb/31764.pdf (accessed May 2010).

4

Sweeney, A.W., R.D. Cooper and S.P. Frances. Distribution of the sibling species of Anopheles farauti in the Cape York Peninsula, northern Queensland, Australia. J. Am. Mosq. Control Assoc. 1990; 6: 425-429.

5

Heymann, D. L. Control of Communicable Diseases Manual. 19th ed. Washington, DC: American Public Health Association; 2008.

Acknowledgments The authors thank the HAT team. For providing environmental health historical data and information we thank Steven Donohue, Queensland Health, Allan McManus, Defence Support Group, and Ben Bassaington, Serco Sodexo. Finally we thank LTCOL Andrew Williams, CO 2 HSB, LTCOL Lachlan Sinclair, CO 1 HSB and LTCOL Robert Cooper, CO AMI for their support and guidance.

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humanitarian aid

A Vision for Indonesia Colonel John Crompton

Colonel John Crompton has been the Consultant Ophthalmologist to the Surgeon General ADF from 1994 to 2011 and Chairman of the Ophthalmology Consultative Group to the Director General Defence Health Service. His military service began with Adelaide University Regiment in 1965 and after graduating 2Lt R A Infantry in 1970, transferred to the RAAMC with successive postings to 3 Field Ambulance, 27 RSAR, 3 General Hospital, 6 Field Ambulance, SO2(Med)to 3 Military District and Consultant Ophthalmologist to 4 Military District. He is a Clinical Associate Professor and Head of the Eye Department and Head of the Neuro-Ophthalmology Service at the Royal Adelaide Hospital. His lack of overseas postings has been compensated by teaching and operating commitments (mostly Aid) in 18 overseas countries. He is a Past-President of the Royal Australian and New Zealand College of Ophthalmologists. Correspondence: jlcrompton@internode.on.net

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The John Fawcett Foundation (JFF) / Yayasan Kemanusiaan Indonesia (YKI) is a tax-deductible Non-Government Organisation principally funded by Australian donors .It provides free eye care including spectacles and cataract surgery to the poor of Bali, Lombok and other islands of the Indonesian Archipelago – Australia’s closest neighbours, where the incidence of cataract blindness is one of the highest in the world. As is usual in most countries, eye care is “user pays” and, due to their poverty, poor people in Indonesia cannot afford the bus ticket to the nearest hospital where eye surgery may be available – let alone pay for the operation. At the request of local councils and village leaders, the JFF has for the past 20 years been sending teams out to the villages and rural areas to vision screen and provide free glasses and eye care. Those who are cataract blind are immediately offered surgery in a mobile eye theatre.The theatres are on board purpose-built buses and are equipped for modern small incision cataract

51

surgery and intraocular lens implantation. Thirty two thousand patients have received these sight-restoring operations gratis. The Indonesian military (TNI) are actively engaged in â&#x20AC;&#x153;Aid to the Civilian Powersâ&#x20AC;? projects and have joined forces with the JFF providing logistic support such as free Hercules aircraft transport of the buses and personnel, and assisting with logistics. For the last four years I have been assisting JFF by training the screening teams and up skilling the young civilian Indonesian ophthalmologists who are employed by JFF to do the surgery. Last December, 2010, I was privileged to teach three full-time Indonesian Airforce ophthalmologists: Lt Col Elisa Manueke from Solo, Lt Col Yuniati Wisma from Yogyakarta and Lt Col

Djonny Djuarsa from Bandung at the West Lombok Hospital. This coaching has enabled them to cope with the surgical load resulting from subsequent screenings in joint exercises. Recently a joint activity in Bengkulu, Sumatra, was attended by military representatives of countries of the South East Asian Pacific area. Representatives of the RAAF and the United States Surgeon Command (USARPAC) also attended. Planning is in place for a joint activity involving the RAAF, JFF and Indonesian Air Force with the promise of great benefit to the blind poor in impoverished communities. In keeping with best practice, we are currently completing and preparing for publication, an audit of the last 500 cataract operations in order to improve future visual outcomes.

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practical advice

Tactical Aeromedical Evacuation Commander Bruce L Greig RANR

CMDR Bruce Greig joined the RANR in 1991. His deployments include Banda Aceh, the North Arabian Gulf, East Timor in 2003 and 2006. His most recent deployment was on the US led Pacific Partnership 11. He is presently Professional Liaison Officer for Reserve GDMOs and he is also a Duty Fleet Medical Officer. Dr Greig is a GP in the Sydney CBD and with specific interests in Tropical Medicine and Underwater Medicine. Correspondence: greigs@ozemail.com.au

Abstract Aeromedical evacuation (AME) is a necessity in the Australian Defence Force and particularly in the Royal Australian Navy. Overwater distance is a major concern with medical evacuation. It is not a matter of ‘swoop and scoop’ as long distances can compromise patient safety. Advanced planning, thought and training are essential if these effects are to be minimised. Consideration as to the make-up of the AME team is important as helicopters can be dangerous.

However what might have been the situation if the member had suffered a myocardial infarction and needed urgent medical evacuation? Considerations would have included: the accuracy of the diagnosis, the relative safety of care aboard versus evacuation, the current position of the ship and its distance from the nearest land–based hospital: this being a key determinant of helicopter evacuation. These and numerous other questions are the ever present concerns of the General Duties Medical Officer, medic or coxswain on any of our warships. Life at sea for the Royal Australian Navy has always entailed long transits to distant ports. There is a dual expectation by our government and the Australian Defence Force that every member should receive medical care commensurate with what they would receive at home. There is also a need to maintain the strength of our fighting force (2) .But not all ships or sites are equal. Very few ships have sophisticated forms of diagnostic support available and distance at sea is a tyranny. Therefore, a robust AME capability is essential.

Phases of AME Medical evacuation has three phases (3). They are forward, tactical and strategic.

Introduction It is said that President Harry S. Truman had a plaque on his desk that read “The Buck Stops Here”(1). Almost all doctors have had the same feeling at some time in their lives but none more so than a military doctor on deployment and particularly the lone doctor or medic (the “Provider”) deployed at sea or remote environment. The situation has improved in recent years with the advent of satellite phones and instant communication with senior medical support at home, but still the final responsibility of patient care and dispersal is reliant upon personal clinical judgement of the provider. Recently the Australian Defence Force joined with the United States Navy in Operation Pacific Partnership 2011. During the commemoration of the ANZAC Dawn Service one of our own sailors collapsed. Stoic to the end he rejoined the ranks only to collapse again. The Sickbay on USS CLEVELAND (LPD 7) was on standby to receive him and did so. Bloods were taken, an electrocardiograph performed and intravenous fluids given. As it transpired the member had an innocent syncopal episode. ADF Health | Vol 12 No. 1 | 2011

i Forward medivac is the movement of the casualty from site of injury to a more secure site with better medical facilities but still within the area of operations (AO). At sea this may simply be from an engine space to the sickbay or returning from an incident on a SIEV (suspected illegal emigrant vessel) back to the ship. These may be dangerous and complicated. As part of standard operating procedure on board all ships they are tested on an almost daily basis. It is the subsequent steps in evacuation that demand the most careful preparation and planning by the medical provider. ii. Tactical medivac is the movement of the casualty from the AO back to intermediate level of medical care still within the AO iii S trategic medivac is the final stage, returning the casualty to the highest level of care outside the AO. Strategic medivac has been formalised in the RAN and has now become the domain of the Royal Australian Airforce (4). A specialised team has been developed for this task. With input from

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Considerations So the decision for AME has been made. What must be considered and put in place? 1. There must be discussion with the receiving facility. As full a brief as possible is an imperative and comprehensive handover notes supplied. The Australian Defence Force has developed a Field or Transport Report (PM 377) which is succinct but has space to record in-flight notes. 2. Helicopter flight has its inherent problems the major one being the stress of flight itself. An acronym worth remembering is GHOSTBN(6,7). The physiology of flight cannot be given comprehensive treatment here but some of the potential problems include: CMDR Bruce Greig RANR supervises an AME from Luganville to Port Vila, Vanuatu of a critically injured Australian tourist by French Puma helicopter from HMNZS Canterbury with NZDF surgical team and USN and NZDF flight nurses on Pacific Partnership 2011.

the providers involved including the primary contact provider and the Duty Fleet Medical Officer, strategic AME is organised from Australia by means of either a formally tasked transport mode or vehicle of opportunity(5). The major mode of evacuation transport today within the Navy is by air due to the overwater distances needed to be crossed. Thus the focus of this paper is Aeromedical Evacuation as it applies to our ships at sea.

Questioning of Appropriateness The tactical AME involves the whole ship’s company and entails a great deal of planning. The decision to medivac however, is the first step. This is the “stumbling block” as often the patient is in a secure environment on board and several questions must be asked. What extra care can be provided ashore? Is my diagnosis correct? Is the patient safer on board than in flight on a helicopter over water for a long period? At times the answer is straight forward such as with an acute abdomen or fracture dislocation with vascular compromise but what of a lower grade abdominal pain or fracture without neurovascular compromise? In recent times a member of the RAN developed renal colic in transit from Japan to Canada via the northern route close to the Aleutian Islands. Return to Japan would have pre­v­ented the ship from meeting a planned refuelling rendezvous at sea and subsequent ceremonies in Canada. A possible medivac to Vladivostok was dismissed in favour of a medivac via US Coastguard Cutter to the Aleutians and then by USAF C130 south. The question must be asked however, whether renal colic needed medivac in the first place. Decision making therefore has to be made as a team. The ship and the medical provider must be the final arbiters although telephone assistance is always available. Nowadays there is a 24 hour phone link to the Fleet Medical Officer (FMO) or his/her deputy. These doctors are always happy to give both clinical advice and advice gained from years of experience at sea themselves. They will always seek further specialist advice when necessary. However they cannot make the decision: the provider beside the casualty has that responsibility, based on their own skill set and capabilities.

G G forces H Humidity O Oxygen saturation S Shakes and vibration T Temperature B Barometric Pressure N Noise Both patient and support personnel must be prepared.

• G forces and unusual movement can cause nausea and exhaustion. Consider preparing the patient with anti-emetics. • Humidity changes play havoc with mucous linings. Decreased humidity dries mucosa causing swelling and necessitates superior airway control. Other inhalants must also be considered. Smoke and fumes can be part of the original injury but exhaust gases in the helicopter can also contaminate. For example in a Sea King helicopter the airflow when the cargo door is open is from aft forward admitting exhaust gases into the cabin. • Oxygen saturation decreases with altitude. Blood loss results in decreased oxygen delivery to tissues. The combination of these two factors can prove problematic in AME. Altitudes of AME flight vary depending on need (8). Minimum flight altitude during the day is 50 feet and at night 100 feet. The more usual altitude is between 500 and 1000 feet for safety. The author was recently involved with an AME in northern Vanuatu where an Australian tourist virtually exsanguinated after his femoral artery was transected. The casualty was flown at an altitude 500 feet rather than at 1000 feet in order to maintain oxygen saturation .There was no available supplementary oxygen and climbing to an altitude greater than 500 feet caused dangerous elevations in the patient’s blood pressure threatening his vascular anastomosis. • Vibration is inherent to helicopter flight. Apart from exhaustion, effects on vision, back pain, numbness and nausea it must be remembered that vibration can displace clots causing further haemorrhage, dislodge monitoring equipment and IV lines, increase patient pain and generally render the job of medical monitoring more difficult (9). Remember to protect the unconscious patient from rub spots on stretchers. • Temperature at altitude decreases contrary to the legend of Icarus. Over water this decrease is 2 degrees Celsius

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per 1000 feet from ambient sea level temperature(8). It is necessary to prepare both patient and flight crew accordingly. • Barometric pressure is inversely proportional to altitude in accordance with Boyle’s Law. So as a helicopter ascends the ambient pressure decreases. Gas trapped in body cavities therefore expands. Sites of importance include teeth, ears, sinuses, lungs, gut and post surgical spaces. Of these the most important are the lungs and the potential for pneumothorax, air embolism and pneumomediastinum. Gas in the eye following penetrating injury is another major concern. Helicopters are often used for the transport of injured SCUBA divers so remember for decompression sickness (DCS) the flight needs to be low to prevent the expansion of nitrogen bubbles. • Noise: Military helicopters are noisy to the point where normal speech is almost impossible. A series of hand signals is needed and hearing protection is essential. Even if the patient is unconscious and intubated, their hearing must also be protected. If at all possible communication via headset and microphone with the flight crew is useful. AME personnel should request this where it is available. Other factors that need to be considered for patient and support staff should include: i. Patient comfort: The patient will be invariably nervous. The author recently medivaced a young NZ Army signaller with appendicitis and septicaemia from HMNZS Canterbury during Pacific Partnership 11. Despite his pain he was terrified of the flight. Reassurance and explanation before loading are essential. Remember the unconscious patient in particular. These casualties are vulnerable.Measures must be taken to protect their hearing, cover their faces from rotor wash, cushion them from the vibration (by padding exposed body parts) and keep them warm. ii. Distance: Helicopter range is limited and as such can be a decisive factor. The S70 Seahawk has a range of 420 nautical miles (NM) on internal fuel tanks and 540 NM with external tanks attached. However, if the helicopter is landing on another ship, the external tanks can interfere with the RAST system needed to land in rough conditions so are usually not employed(7). Therefore the distance for a required medivac must be assessed early and quickly. Recently HMAS KANIMBLA en route to Hawaii needed to medivac a sailor with an acute abdomen. The distance to the next facility was excessive so HMAS WARRAMUNGA moved ahead to provide the medivac helicopter with an intermediate refuelling site. By doing this the target destination of Hawaii could be reached. Extended distances can also create the need for night flying. Military pilots employ night vision equipment but passengers in limited cabin light must be able to identify medical equipment easily. iii. Preparing for failures. Remember that batteries run flat and gases run out. Medications wear off and it is almost impossible to draw up more en-route. Be prepared before departure.

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iv. Confined space. Medivacs are conducted in restricted spaces which prevent any real medical interventions during flight. Pre-flight preparation by the AME coordinator is essential and should not be hurried by undue pressure from the ship’s commander. As mentioned earlier, during Pacific Partnership 11 we had to perform a tactical medivac of an Australian citizen from Luganville to Port Villa in Vanuatu. Those involved included a New Zealand surgical team, French helicopter from HMNZS CANTERBURY with both a New Zealand and US flight nurse, co-ordinated by the Australian OIC of the hospital medical site under the auspices of the US Navy command (DESRON 23) in USS CLEVELAND. The OIC stood his ground and the extra half hour on the ground was finally accepted by all stakeholders. Time in preparation; urinary catheter, central venous access, appropriately secured endotracheal tube and careful briefing prevented potential problems. Emphasis must be given to this as tracheal re-intubation is often more difficult. Aboard a helicopter in flight it is life threatening.

Who flies? Flight in a helicopter is always exciting and dangerous. The default position is that the doctor needs to fly for the patient’s safety. However this author believes that alternative health personnel may be equally satisfactory. If the preparation has been comprehensive then little more effort by the medical officer should be required. In the event of a dramatic deterioration of the patient during flight then the ideal strategy is to land. Over water that is not an option. The best option is to supply two escorts and on a ship this might include the senior medic and a SMET (member of the Ship’s Medical Emergency Team). The health staff embarked must have the capacity to advise the flight crew correctly and be able to supervise patient movements. The loss of a helicopter with the lead medical officer on board could compromise a whole mission.

In Summary Tactical and ultimately strategic medivacs are not a matter of “swoop and scoop”. Advanced planning, thought and training are essential. From the moment a Navy medical officer joins his new unit he should assess the medivac capabilities of his new unit. He must ensure that the existing mechanisms for medivac are truly functional and achievable. If not then ‘make it so’.

References 1. http://www.phrases.org.uk/meanings/the-buck-stops-here.html 2. ADDP Refers to Australian Defence Doctrine Publications 3. ADDP 1.2.1.3 _ Philosophy of Health Doctrine 4. ADDP 1.2.5.41 – Health support to Operations 5. ADDP 1.2.5.43 - Health support to Operations 6. HPD ( Health Policy Directive) 801 – Aeromedical Evacuation Terminology 7. Courtesy of Operational training flight, HOCU 8. My thanks to LCDR Stephen Dickfos RANR (Observer 816 Squadron) for flight and aircraft details. 9. Lecture by Dr Glenn Pascoe WGCDR RAAFSR 10. I wish to pay special acknowledgement and sincere thanks to SQLDR Paul McGinty RAAF for his enduring friendship, support and guidance, teaching me the pitfalls of AME.

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occupational health

Fitness to Serve Steven Sponberg BMech(Eng) MFOM, ATPL Captain Mike O’Connor AM Brigadier Stephan Rudzki AM

Steve Sponberg is ex- RAN and has a broad aviation and engineering background working as both a pilot (Helicopter) and contract engineer throughout the world over the past 20 years. While working in the Solomon Islands and Timor, he carried out numerous medivac flights including winching 3 critically injured sailors from deep water fishing vessel and delivering them safely to medical facilities. Steve Sponberg is currently Senior Project Manager for the MEC Implementation and Project Team. Having managed a number of large Defence projects throughout Australia and combined with his aviation medical background, the author brought significant experience and assisted with the success of the MEC Implementation project Captain O’Connor is the current Editor of ADF Health and a practising obstetrician and gynaecologist.He is also Section Editor of the Journal of Law and Medicine. Before joining the RANR in 1982 he spent 6 years as a Regimental Medical Officer attached to 31 Signal Regiment in London.

Brigadier Rudzki joined the Army Reserve in 1975 after completing high school. He become an officer cadet in Adelaide University Regiment in 1977 while completing his medical studies, and graduated as a 2nd Lieutenant in the Royal Australian Army Infantry Corps in 1980. He joined the undergraduate scheme in his final year of medicine and on receiving his medical degree from Adelaide University in 1982 he transferred to the Royal Australian Army Medical Corps. Brigadier Rudzki has served in a variety of junior Medical Officer postings, including the 2nd Military Hospital , Regimental Medical Officer in the 3rd Battalion (Para), 8/12 Medium Regiment (Artillery) and the 1st Recruit Training Battalion. Brigadier Rudzki took a year of leave without pay in 1986 to work with the British Army as a Senior House Officer in Rheumatology and Rehabilitation at the Queen Elizabeth Military Hospital in Woolwich. Command and staff appointments have included SO2 Medical at Headquarters Second Military District (1988-89), Officer Commanding Medical Company and Medical Support Company 1st Field Hospital (1989 -1991), Officer Commanding Albury-Wodonga Medical Centre (1994-95) and Commanding Officer of Canberra Area Medical Unit (1997-1999). Brigadier Rudzki served as an exchange with the United States Army at the US Army Medical Department Centre and School in San Antonio Texas (2000-01). While there he worked in the areas of Telemedicine and electronic health records.

Higher education achievements include a Graduate Diploma in Sport Science (Cumberland College 1986), Master of Public Health (Sydney University 1997), and Doctor of Philosophy (Australian national University 2009). Brigadier Rudzki has had a long standing interest in reducing injury in military recruits, and has published a number of research papers on the subject. He was awarded a Defence Force Fellowship in 1993 to document and compare Injuries in the Australian Army with Allied Forces. He was also responsible for the introduction of the Defence Injury Prevention Program in 2003, and his PhD thesis was titled “The Cost of Injury to the Australian Army”. He was awarded a foundation Fellowship of the Australasian College of Sports Physicians in 1991. Senior staff appointments have included Director of Preventative Health, Defence Health Services Division (2003-2005), Director of Occupational Health and Safety – Army (2005-2008) and inaugural Director of Army Health (2008-09). As the inaugural Director of Occupational Health and Safety, Brigadier Rudzki was responsible for the introduction and implementation of Army’s Safety Management System and oversaw the introduction of Army’s Risk Appreciation process. Operational postings have included Indonesia (2 Field Survey Squadron, May-Aug 1983), Western Sahara (MINURSO April-Nov 1992), Bougainville (Officer Commanding Combined Health Element Oct-Dec 1999), East Timor (Chief Medical Officer for the United Nations UNTAET, July 2002 Jan 2003) and the Middle East (J07 HQJTF633 July-Nov 2009). Brigadier Rudzki received a Commander Logistics Command Commendation in 1994 and was awarded membership of the Order of Australia in 2005. He is currently Director General Strategic Health Coordination in Joint Health Command. Correspondence: steven.sponberg@defence.gov.au

Introduction Physical fitness and medical standards in the military are intended to ensure that recruits are able to meet the rigorous demands of service life (1) To determine whether a soldier was fit to serve in the United Kingdom or overseas during the South African War of 1899-1902 a system of medical classification was developed (1) This classification was subdivided during WWI following the gazetting of the Military Services Act (1916) UK: a series of lettered categories was introduced. The United States Army introduced a screening program in 1917 for its officers, draftees and enlisted men to identify by psychological testing those men whose defective intelligence would make them a menace to the military organisation’(2) The modified system in the UK was chiefly designed to assess traditional infantry soldiers but failed to meet the demands for

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AUSTRALIAN Idol judge Ian “Dicko” Dickson broke into a sweat under the discipline of an Army Physical Training Instructor (PTI) during his recent visit to East Timor. Dicko visited East Timor for a series of live broadcasts from Operation ASTUTE in July 2009 for Melbourne’s Vega FM. Dicko was entertaining the troops of Timor Leste Battle Group 6 (TLBG6) as part of a Forces Entertainment Tour which also included performances from Australian music legend Ian Moss.

more specialised technology-skilled manpower during WWII. This was because: 1) it did not adequately define physical or mental limitations 2) it failed to describe any emotional or mental weaknesses and 3) it failed to adequately describe specific disabilities. As Fletcher explained: The range of employments available in the modern Army is extremely wide and varied, and each individual job brings into use different mental and physical functions (1). These weaknesses prevented posting staff from selecting suitable roles for soldiers with disabilities and thus maximising their utilisation in the total manpower. Minor disabilities were compatible with training jobs in a home base but were not acceptable for a soldier posted into an active combat role. So the lettered system was wasteful. The Canadian forces under the leadership of MAJGEN Brock-Chisholm, Director General of Army Medical Services, introduced a new Army medical classification in 1943 called PULHEMS. This 7-category system of physical and mental ‘qualities’ included assessments of physical capacity (P), upper limb function (U), locomotion (L), hearing (H), eyesight (E) or (EE) in the subsequent British PULHEEMS system, mental capacity (M) and emotional stability (S). After a practical evaluation of the Canadian system among British forces, a similar system was introduced by the British Army in 1948. Each of the seven ‘qualities’ were graded (up to 8 levels). If a soldier was classed as P6 he would be fit for ordinary work but would not be deemed to have the stamina even after

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training to endure the strain and fatigue of full combatant duties. He could however be posted for restricted duties in a temperate climate. The RAF and RN insisted that for their respective personnel each eye be tested separately, with and without the aid of spectacles. So visual acuity was quantified bilaterally (EE). If a serviceman was assessed as virtually deaf (degree 8 for “H”) then he would be unsuitable for any military service. If a soldier’s eyesight was at least degree 3 in each eye (visual acuity =6/12) or he had one eye equal to grade 1 (6/6 vision) and the other eye equal to grade 6 (6/36 vision) then he could be deemed suitable to both drive and shoot. The PULHEEMS score could be used to designate soldiers’ eligibility for service by means of a 2-letter code: FE (Forward Everywhere); FT (Forward Temperate);LE Lines of Communication, Everywhere);LT (Lines of Communication in Temperate Zones); BE (Base Everywhere); BT (Base temperate) and HO (Home only). For example climatic restrictions to temperate zones were introduced by the British Army for men who had sustained eye, ear, skin and psychiatric illness in the tropics. This prevented unnecessary losses to their manpower. The PULHEEMS system catered for such restrictions by downgrading such soldiers under the P, S and M qualities. In Australia the PULHEEMS system was adopted by the Army but subsequently incorporated as an adjunct to a Joint system of Medical Employment Classification (MEC). PULHEEMS described the physical and mental qualities of Army personnel, whereas the MEC system describes the suitability, in all three

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Services, for employment and deployment, with short or long term physical restrictions and/or medical support. Under the old MEC system, MEC 1 personnel had no restrictions, MEC 2 personnel were deployable with restrictions, MEC 3 personnel were temporarily non-deployable and MEC 4 personnel were permanently non-deployable. In the ADF there has been a 4-5% decrease in the proportion of personnel deemed fully fit over the past 4 years. (6) Since April 2007 Navy personnel with a MEC1 category have fallen from 75% to 69%, personnel in Army have fallen from 74% to 70% and in Airforce MEC 1 personnel have fallen from 75% to 71%.There have been commensurate rises of between 2-6% rises in MEC2 personnel. Those with the lowest category MEC4 have remained static with between 1-2% of the workforce represented .The total permanent uniformed service personnel was 59,541.

The new MEC system (2) Before introducing the new MEC system in July 2011 there were extensive discussions with stakeholders in November and December 2010 .These involved the MEC Implementation Project team and regional health professionals. It was a key driving force for the new MEC design. The new emphasis is on rehabilitation and return to work. “MEC policy is being reviewed to provide greater flexibility for employment for members with permanent injuries. A key principle of the revised MEC structure is to focus the allocation of a classification not solely on the physical restrictions and health support requirements, but also on the inherent physical requirements necessary for employment in specific operating environments. In this way, the revised MEC structure seeks to maximise flexibility in employment options for Army’s workforce managers and commanders.” http://www.army.gov.au/woundeddigger/Welfare_Boards.asp viewed 20 Aug 11 The ADF recognises its obligation to wounded or ill members and favours rehabilitating its own personnel rather than transferring them to the Department of Veterans’ Affairs or into private rehabilitation facilities. This is one reason for the 20 year low rate of separations in 2010:7% (6).The new system further extends this principle. The new MEC system has 5 categories: • MEC1:Fully Employable and Deployable • MEC2: Empoyable and Deployable with Restrictions dependent on available health support and the exact physical demands of a member in certain employment environments and location. • MEC3 Rehabilitation. Member not fit for operational deployment. It signifies that there is an injury or illness or a pregnancy. The expectation is that the member so categorised will eventually return to a deployment classification. • MEC4: Employment Transition: This means that the member will not recover sufficiently to return to their original occupation but may be offered an alternative occupation or a limited return to their original occupation.

• MEC5: Medically unfit for further service. The member is in the process of separating from the ADF because of their medical condition. The new Extended Rehabilitation classification (MECJ32) is more closely aligned with the Rehabilitation and Compensation Act 2004 (C’th) .It allows members more extended time to recover (up to 24 months) and return to their former occupation .If complete recovery is impossible then members will be retrained for similar jobs nearby or at worst completely new jobs .Each of the 5 categories has a number of new sub-classifications which are based on the member’s primary military occupation. These environmental categories will include: a. Joint (J). This is the default environment code for all personnel within the ADF. It is predominately used for all ‘unrestricted’ deployment personnel b. Land (L). This is used for Army personnel only with significant employment restrictions c. Maritime (M). This is used only for ADF personnel attached to a maritime environment who have employment restrictions So for example J11 & J12 will replace the former MEC101.This will include members who are fully employable and deployable. The J12 category will include personnel wearing spectacles, foot orthotics and taking anti-cholesterol medication. Those members who are deployable with restrictions would include representatives from 5 Land and Maritime employment restricted categories as well as 4 Joint categories. : J21, J22.J23, M24, M25, M26, L27, L28 and J29. Formerly those members would have belonged to one of 5 codes: MEC201, 202,203,204 and 205.

Surveillance Currently the ADF requires full time members to undergo a Comprehensive Preventative Health Examination (CPHE) every five years to annually, depending on age. A briefer Annual Health Assessment was conducted between CPHE. From 1 October 11 this will be replaced by a new Periodic Health Examination and MEC Review. The frequency of this PHE/MECR will be based on age and Service. At each episode the MEC will be allocated or confirmed. In between Preventative Health Examinations members employed in specialist occupations such as clearance divers and aircrew will be required to undergo an annual examination now called the Specialist Employment Classification Annual Health Examination (SPECHA). For Reservists Annual Health Declarations (AHD) will be introduced for those years that do not require physical examinations.

Sources of Information about the new system Training modules are available to all ADF members with more specific instructions available to: 1. administrative staff, nurses and medics-this details the roles and responsibilities of these health staff

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2. Doctors and MEC Conductors-this outlines the methods for assessing and allocating MEC

Bibliography 1.

Assessing Fitness for Military Enlistment, Physical, Medical, and Mental Health Standards Paul R. Sackett and Anne S. Mavor, Editors Committee on the Youth Population and Military Recruitment: Physical, Medical, and Mental Health Standards. Paul R. Sackett and Anne S. Mavor, Editors Board on Behavioral, Cognitive, and Sensory Sciences Division of Behavioral and Social Sciences and Education (Washington, D.C.,National Academies Press;2006.)

2.

Morabia A, Zhang FF. History of medical screening: from concepts to action. Postgrad Med J 2004 80:463-469.

3,

For those readers with DRN access please access the Joint Health Command website or use the link:

Fletcher RT.PULHEEMS A New System of Medical Classification. Br Med J. 1949 Jan 15; 1(4593):83–88.

4.

DI(G) Pers 16-15

http://intranet.defence.gov.au/vcdf/sites/MECSystem/com web.asp?page=67323&Title=Home%20Page

5.

HD 242

6.

HD 236

7.

Navy News April 28, 2011.

8.

Sean Parnell. Drop in deployment-ready Defence personnel. The Australian June 8, 2011

3. Confirming authorities-this details the requirements for assessing and allocating an MEC In addition two further training packages are planned: • for Commanders informing them of the MEC System and outlining their responsibilities • for ADF members outlining the processes of the MEC Review Board from a medical perspective

For those readers without DRN access information can be sought online at: Mec.Implementation@defence.gov.au

Aurora Australis Training Cruise to Macquarie Island Seaman Medic Danielle Dickinson, takes a blood pressure reading from a patient for their annual medical, onboard the RSV Aurora Australis. Thirty-one trainees from various categories of employment within the Royal Australian Navy (RAN) are on board the RSV *Aurora Australis* for an Antarctic trip-of-a-lifetime. The group, which includes Marine Technicians, Medics, and Communications Information Systems sailors under-training, ten General Experience ‘Gap Year’ sailors, and their supervisors, are sailing on the RAN leased P&O Icebreaker *Aurora Australis* to Macquarie Island, located in the subantarctic region, north of the Antarctic continent. The voyage is being conducted to pick up a group of Australian Antarctic Division employees who have been stationed at the world heritage listed island to carry out pest eradication activities. It will give the Navy’s embarked trainees the experience of serving in extreme weather and oceanic conditions, rarely ever seen by Navy personnel.

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military history

The Heritage of Naval Surgery Lieutenant Commander (Professor) Noel Tait RANR

Introduction LCDR Tait is a general surgeon with interests in upper gastrointestinal cancer surgery. He has been a consultant surgeon to the ADF since 1985.Prior to his current appointment in 2008 he was Associate Professor of Surgery at the Australian National University Medical School (ANU) and Sub-Dean of the ANU Clinical School at Calvary Hospital in Canberra. In 2008 he was awarded a Rotary International Fellowship in recognition of community services in medicine and cancer care.LCDR Tait currently acts as Reserve Coordinating Officer Fleet Health. Correspondence: ntait@uow.edu.au

Surgeons in the modern Royal Australian Navy (RAN) share a rich history and heritage handed down to us, particularly from surgeons of the Royal Navy during the age of sail from the 16th to the late 19th century.to1900. Naval surgery became a separate branch of military surgery. It became standard practice to include surgeons as a standard part of a ship’s scheme of complement. Areas of each ship were allocated for surgeons to operate using surgical instruments and supplies and assisted by medical sailors. The discipline of naval surgery evolved to include specific training for surgeons in the treatment of common illnesses encountered at sea - this being previously the responsibility of ships’ captains. The first hospital ship, Therapetia, a trireme, accompanied the Athenian fleet in the 5th century BCE (1). Much later, in 1608, the Royal Navy (RN) provided its first hospital ship Goodwill for an expedition to Algeria (2). During the Crimean War 100,000 wounded British soldiers were repatriated by Royal Navy Hospital ships(3). Surgeons of the Royal Navy became indispensable members of fighting ships, facilitating the return to duty of wounded sailors and boosting shipboard morale by their caring humanitarian approach. This paper follows the landmarks which produced this unique heritage. Four periods of naval or military surgery will be described: 1) ancient Egyptian surgery between 1700 and 3000 BCE; 2) 16th century developments in wound care; 3) the 19th century care of convicts during their transportation to Australia from England; and 4) examples of executive skill, courage and innovation displayed by 20th century naval surgeons in war and in support of peace-time civilian crises.

The History of Military Trauma Surgery The frozen remains of a Neolithic hunter were found by two walkers in the Otztal mountains on the border between Austria and Italy in September 1991. This discovery revealed the earliest evidence of rudimentary wound care occurring at least 3,300 years BCE. ‘Otzi the Ice Man’, as he came to be known, died of a massive haemothorax 5,300 years ago following penetrating chest trauma: an arrow had pierced his left thorax and lacerated his left subclavian artery.( 5,6,) The remains of primitive wound dressings applied to Otzi demonstrate that

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even in prehistoric times conflicts inevitably required medical support. Only 300 years later, in 3000 BCE Egyptian court physicians began to record their surgical treatments – mostly of the ruling class. The earliest naval surgery developed pari passu with the trauma incurred in the earliest naval warfare (1)

The Edwin Smith Papyri-a textbook of ancient Egyptian surgery Edwin Smith was a British archaeologist who discovered ancient medical tracts, written in ancient Egyptian Hieratic script around 1700 BCE. They represent our oldest known surgical treatise. The case descriptions and treatment recommendations recorded in them were based on clinical experiences accumulated by earlier court physicians up to 1,000 years prior; that is from approximately 3,000 years BCE. (7, 8) The ancient surgeons responsible for compiling these cases used what clinical information was available to them to diagnose, determine prognoses and advise on treatments, much as contemporary clinicians do today. However, unlike current practice, there was no diagnostic support. The competence of ancient surgeons depended on their use of innate intelligence, knowledge and clinical acumen. What few surgical instruments they possessed needed to be applied with skill and courage. The Edwin Smith papyri systematically describe injuries starting at the head and proceeding downwards through body regions like a modern anatomy textbook. The treatments are remarkably rational and there is little recourse to magic. The cases discussed in the Papyri are classified into three clinical prognoses: favourable, uncertain and unfavourable, much as modern triage does. An unfavourable clinical verdict was delivered in ancient Egyptian words meaning ‘an ailment not to be treated’. Nevertheless such patients still received humane care scientific interest and the best possible attempts to alleviate suffering in under-resourced and austere circumstances, often in war. One example of an unfavourable outcome was chest injury with pneumothorax. Surgeons of the time understood that attempts at treatment were futile and inhumane. Far more treatable trauma patients occurred on the battlefield and these received higher priority. Due to the tenacity, skill and innovation of subsequent generations of military surgeons chest injuries with pneumothorax are now effectively and safely treated by surgeons.

Ambroise Paré. Surgery has advanced over the centuries because of the humanity and skill of military surgeons working under the most inhumane and austere conditions; the conditions typical of surgery during war or civilian crisis. Ambroise Paré (1510 – 1590) was such a surgeon who spent much of his surgical life working under these conditions. He advanced the surgical care of war wounds by replacing hot iron cautery for the control of bleeding using ligatures instead. Physicians of Paré’s time mistakenly attributed the terrible septic outcomes from war wounds and operations to the effects of a poison in gunpowder. Reasoning that this could be neutralised by heat, they prescribed cautery of wounds with

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boiling elder oil. The standard of care was to pour boiling oil over open amputation wounds after surgery. To heal the stump, the edges were left open to heal slowly by secondary intention. This was intended to improve the survivability of the soldier (or sailor) from the injury. However the extra trauma induced by cautery caused horrible pain and further diminished the already compromised physiologic reserves of the unfortunate victim. During the Siege of Turin in 1537 Paré’s supply of elder oil ran out. Driven by his desire to provide optimum treatment to those under his care he confiscated supplies from the palace kitchen and concocted a substitute made of egg yolks, oil of roses, and turpentine. This was applied cold to the amputation wound because there was no fuel. When he anxiously reviewed his soldier patients the next morning Paré found the conventionally treated patients in pain and unwell and mostly delirious while those not cauterised were comfortable, clear headed and relatively free of pain. (9, 10) Paré proved that relief of pain was important and overturned conventional wisdom using his own powers of observation and innovation. He described his findings clearly, recognising their significance and arguing that his innovative practise produced better patient care. Paré’s new treatments were finally accepted by the majority of his contemporaries.

Surgery in the British Navy Naval surgeons participated in the growth of naval power which proved crucial to the development of the British Empire. The practice of naval surgery had its origins in the era of the Tudor navy of King Henry VIII when gunpowder and cannon were introduced. Sea travel and sea warfare, already cursed by diseases related to the cramped conditions on sailing ships, poor nutrition at sea and exposure to diseases in foreign lands, now produced horrendous wounds resulting from explosions and missiles. While fire had always been a threat to sailing ships, the advent of explosive munitions brought searing blasts, sudden fierce fires and overwhelming exposure to noxious gases not previously experienced. Prior to the advent of firearms, naval battles consisted of ramming, fire ships, archery and close quarter combat between crews whose ships would be deliberately entangled to facilitate boarding and counter boarding. Fighting was hand-to-hand, between sailors armed with weapons that bludgeoned, stabbed and slashed one victim at a time. If they impeded the ability of the combatants to get at each other, the dead and injured were thrown overboard. Naval battles under sail in the era of explosives were often carried on at very close quarters with ships locked together, cannons and muskets blasting away at point blank range. The pattern, the number and the rate of accrual of injuries escalated rapidly. (11) Surgeons in such battles described large numbers of severely injured men that quickly swamped the limited space and resources that could be allocated to their care in a sailing warship

Naval surgeons in convict ships to the Australian colonies. The vessels engaged in transporting convicts to the Australian penal colonies were overcrowded, poorly equipped merchant

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ships. Though comprised of chartered merchant vessels, the First Fleet was sponsored by the British government with the commissioners of the Royal Navy responsible for supervising the vessels’ refits and victualling in preparation for the voyage to Port Jackson. Few of those responsible understood the magnitude of the journey. A naval surgeon was posted to each ship. (12) These were men steeped in the traditions of the navy and most importantly they understood the ethics of naval service. These naval surgeons had to care for crews, convicts, fee-paying passengers and marine detachments alike. They also resisted the unbridled cruelty and inhumanity of masters who had learnt the craft of transporting humans as cargo in the slave trade, mainly between Africa and America. Ships’ surgeons also exposed the callous greed of the ship owners who repeatedly sent unseaworthy, under-victualled ships on the long voyage to Australia without any concern for the health or safety of the convicts and crews. These naval surgeons had acquired vast experience in treating injuries during war and in managing the health of crews on protracted voyages and in foreign climates. They were uniquely qualified for the roles that befell them during the era of convict transportation. The surgeons of the First Fleet lost few convicts to disease or trauma. Transported convicts had spent months in fetid prison hulks while awaiting transportation to Australia. Some of those transported on the first fleet were fitter on arrival at Botany Bay than when they left England. Sadly, subsequent fleets did not fare so well, principally because the naval surgeons were removed from them. Responsibility for fit-out, victualling and allocation of ship surgeons in subsequent fleets sent to Sydney Cove became the responsibility of private contractors. Though these contractors were required to work to Navy standards, abuses were common. Consequently death rates on the voyages rose disastrously once the contractors were free to appoint and to control their own surgeons. The Second Fleet, which was managed purely by private contract, was a disaster. Almost 300 of 1000 convicts transported died during the journey from disease, sadistic floggings, general neglect, and the withholding of rations and clothing. Those who survived were sold at inflated prices in markets at Sydney Cove. Another 150 died after landing. Much to the disappointment of Governor Arthur Phillip, the majority of survivors of this fleet were so ill and weakened that they were unable to contribute to the food production and economy of the already starving colony – they simply added to the colony’s burden. In response the Navy commissioners reassumed responsibility for medical care on convict transport ships and placed a naval surgeon on each vessel. They reported to the Navy, rather than to ship owners and their merchant seaman captains. Inevitably conflicts arose between naval surgeons and masters of convict ships. (13) The re-introduction of naval surgeons into the British convict ship system saw the transportee death rate plummet. The embarked naval surgeons were given the special title of Surgeon Superintendent to enhance their status beyond their stated rank. This made it possible (but not easy) for them to balance the commercial interests of ship owners and merchant captains, and the interests of the British Government and naval commissioners. The role of a naval Surgeon Superintendent on a convict transport ship required firmness along with tact and

diplomacy to moderate the cruelty and avarice that confronted them at sea. They did this while exercising clinical skill and experience, tempered by naval discipline, to deliver medical care at sea and to meet the expectations of the naval commissioners at home and Governor Arthur Phillip. The first four ships to make the trip to Botany Bay with naval surgeons again supervising the care of convicts and crew managed to deliver almost 700 convicts, as well as marine detachments and other passengers, with only fourteen deaths incurred and most of the landed convicts fit for work to support the colony. This was a remarkable outcome given the convicts were often in parlous health after being held for long periods in rotting, unsanitary prison hulks before being transferred to the care and protective supervision of naval surgeons in the convict transport ships. One of these Surgeon Superintendents was Thomas Reid. An Irish born graduate of the Royal College of Surgeons, Reid made two voyages on convict ships to the New South Wales colony at Sydney Cove in 1817 and to Van Diemen’s Land in 1820. At that time Royal Navy surgeons were still obliged to allocate part of their small salary to the purchase of a navyapproved kit of surgical instruments before boarding ship. This practice was unlike the army, whose surgeons had their instruments provided for them by the officers and men of the regiment to which they were assigned.(14) Only from 1805 had the Royal Navy finally taken over the expense of providing ship’s medicines, previously also a responsibility of the surgeon, to be met out of his salary. Reid, using courage, common sense and his Navy- approved instruments was so successful in getting his convict and marine detachment charges to Australia in good health that Elizabeth Fry, a renowned agitator for prison reform at the time, cited him as a model for government policy on the care of convicts at sea and a role model for other surgeons. Unfortunately for later transportees war broke out between Britain and France under Napoleon. The Royal Navy, now desperately short of surgeons for its warships could no longer release them for the Botany Bay convict ships. The death rate on convict transport ships soared again. Fortunately there was help waiting at the colony. William Redfern (1774-1833) had trained as a naval surgeon but became embroiled in the mutiny by British sailors at Nore. Though his role was confined to urging the sailors to “be more united amongst yourselves” Redfern was sentenced to hang but his sentence was later commuted to transportation to the Australian penal colony at Sydney Cove. There was a desperate shortage of trained doctors in the colony so Redfern was soon busy doing what he was trained for, attending to the sick whether free colonist, emancipist or convict. Even though he was a convict on a ticket of leave, Redfern was unrelenting in his advocacy for all aspects of health care in the colony: lobbying against excessive punishments (especially the lash), urging improvements in diet and sanitation, agitating for better housing for convicts. Though as a rash young man Redfern had plunged from proud naval surgeon to convicted and transported felon he never lost sight of, or ceased to live by, his naval surgery heritage. He deserved the honour of having the Sydney suburb of Redfern named after him. (15, 16)

The role of a Navy surgeon Naval surgeons are, as are all members of a warship’s complement, responsible to the vessel’s commander. However, the special role served by surgeons as carers for all members

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of a crew, as intellectual companions for ship captains and as sea-going scientists, has permitted special relationships between surgeons and their commanders. The special roles and relationships moulded around surgeons at sea brought unique responsibilities but permitted freedoms that could be enjoyed by the average member of a war ship’s crew. This remains the case today. The twentieth century, though an era of revolutionary technical advances in ship design, sea keeping qualities and war fighting abilities, still required courage and innovation in the provision of surgical care at sea, on the surface and below, at peace and at war. During WWII the USN Surgeon General, VADM Ross T.McIntyre was responsible for an enormous expansion in Navy health care capacity. This was in preparation for the expected massive casualties from naval warfare and amphibious landings needed to reverse the advances made by the Japanese. He leased hotels and converted them to hospitals, took over army hospitals at General Patton’s tank training facilities, lobbied for funds and facilities to improve medical care on war ships and to commission hospital ships and fast-tracked the entry and training of USN surgeons and medical corpsmen. McIntyre’s strategic vision, organisational courage and executive skill were crucial to the campaign. McIntyre did not tire after the Pacific conflict ended, spending the rest of his working life caring for and representing those left handicapped by war wounds. (17, 18) The Pacific war, with its seaborne aerial combat, amphibious operations and fierce Japanese Kamikaze pilots, was a particularly bloody affair for Allied naval surgeons. LCDR Sam R Sherman was flight surgeon on the USS Franklin when it was severely damaged by Japanese bombing on March 19, 1945. A Japanese fighter managed to penetrate the defensive screen around the Franklin and scored a direct hit, setting off a chain of explosions that blew Sherman into the air, concussed and bruised him and blew off his glasses. (19) .In a moment a series of explosions caused hundreds of casualties. Sherman was faced with carnage frequently described by his forebears in the age of sail. Most of Sherman’s medical corpsmen had been killed, blown overboard or injured. Of the other three doctors on board the Franklin one had been killed by the explosions. The other two, trapped by fire in the wardroom, were not rescued for many hours. Sherman managed to collect a group of musicians to help him and, though injured himself and surrounded by fire and chaos, began the business of triage and saving lives. Having spent months preparing himself and his equipment for this moment, exercising for disaster and making his corpsmen exercise again and again, he put preparation into practice. While the Franklin’s damage control crews went about the deadly serious business of saving the ship, Sherman staunched haemorrhage, treated burns and carried out amputations and other emergency operations. His example deserves our attention, the more –so because of the modesty with which he contributed his memories to oral histories collected after WW2. Sherman’s vivid story illustrates the resourcefulness and courage a naval surgeon must deploy to cope with mass casualties on a damaged ship in the middle of a modern era battle. The story of HMAS Hobart and her response to a peace-time crisis on Macquarie Island, in the sub-Antarctic zone

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During early January 1979, HMAS Hobart was berthed in Sydney for maintenance. Many of her crew were on Christmas leave and much of her machinery was at least part dismantled for servicing. While in this state, Hobart was tasked to respond to a civilian crisis on Macquarie Island where a biologist had fallen down a cliff, suffering severe spinal and limb injuries. Though the victim had been retrieved from the site of the accident to the Macquarie Island base, a helicopter rescue was required to move him to a ship-borne medical facility and on to the nearest major hospital, 1450 kms in Tasmania. (20) Hobart, a Perth Class Guided Missile Destroyer, was not equipped to carry a helicopter: an improvised landing pad was required. Hobart’s captain and a hastily assembled crew brought her to partial sea readiness. They sailed her out of Sydney on one boiler, through heavy weather with wind exceeding 30 knots and swells over 5 meters and sailed the 2160kms to Macquarie Island. On the way they converted her quarter deck to a temporary helicopter landing pad. At the island they rendezvoused with the Antarctic mission support ship, Thala Dan. The Thala Dan’s navy-trained helicopter pilot, having retrieved the patient from the island, landed on Hobart’s improvised quarter deck platform in heavy weather. With the patient now under the care of her medical team, Hobart headed to Tasmania, again at speed in heavy weather, even though many of the crew were sea-sick under the violent conditions. After undergoing emergency surgery in the Royal Hobart Hospital the patient was transferred to Melbourne but sadly, in spite of courageous efforts by all concerned, he eventually succumbed to his injuries. This operation illustrates what modern seaborne surgical capability can require. The essential ingredients include personal and team enthusiasm, commitment beyond the normal call of duty by all ranks and disciplines, individual and organisational inventiveness, innovation, adaptability, executive skill and a willingness to work far away from the usual supports of land-based medical practice. Our challenge is to utilise complex modern resources to overcome age old problems that have always beset seafarers: bad weather, geography, distance, isolation and all too frequently, inadequate resources.

Concluding Remarks. Surgeons in today’s navy must be prepared for deployments in training, international exercises, peace time power projection and in any of the dimensions of human conflict and disaster. Deployments, as was the case for the Royal Navy surgeons tasked to the convict fleets, may not always be in war or even to sea. War service for a naval surgeon today may be on land in Afghanistan or in a cramped ship, policing off-shore exclusion zones in the Middle East. A modern naval surgeon may be deployed to support the force protecting international trade from peace-time piracy or to rescue and provide emergency care to asylum seekers on overcrowded and often unseaworthy fishing vessels. They may be required to work in full battle dress in the tiny medical facility on a frigate operating in the constant heat and humidity of a Middle Eastern war zone or in the still cramped, hot and noisy but better equipped facilities on amphibious landing ships. These conditions will improve as design and technology become more sophisticated.HMAS Manoora and Kanimbla (Landing Platform Amphibious or LPA’s) with their Primary Casualty Receiving Facilities (PCRF,

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now MR2E) have been valuable assets for the RAN since 1994. The acquisition of HMS Largs Bay (now HMAS Choules) to replace these decommissioned LPA’s will see more spacious and better equipped medical facilities than were provided on the LPA’s.Medical care afloat will move to even higher levels of capacity and technological sophistication with the arrival of the two Canberra class vessels during the next decade. However, the factors that characterise naval surgical service will remain. Personal and operating facilities will always be cramped. Privacy at sea will always be limited. Ships, powering through seas, embarking and landing helicopters or landing craft, participating in manoeuvres or combat are noisy. The sea will always be unpredictable. We will be expected to innovate to deal with shortages as casualties consume available resources or our supply lines are stretched. In peace-time operations or in war we will be expected to show leadership as we exercise executive skills to cope with imbalances between demands and resources, to model new scenarios, propose new strategies to enhance our performance, and to incorporate the most modern technologies and techniques into our seagoing armamentarium. Our defence force medical services, including those of the RAN, are expected to be ambassadors for Australia and the Service, to be major permissive factors in the increasing power projection role expected of Australia and to be keys to the ability of Australia and her navy to respond to threats and to humanitarian crises at home and overseas. The qualities required are not unique to naval surgeons but are to be found in abundance among them. As military surgeons we take pride in the special nature and circumstances of our work. Fortunately, the navy is not usually at war. Naval surgeons must always have the skill and the will to look after the whole force, in peace as well as in war and if necessary, without the immediate support of other doctors. Life at sea produces a wide range of injuries and morbidities, many of which may be outside the usual patterns individual surgeon may deal with in their civilian life. (21) Advice can usually be sought but isolation and the other commitments a tasked ship may face require the navy surgeon to manage wherever their skills and knowledge are called on and to maintain the training and commitment to do so. The special challenge of naval surgery is to uphold the traditions of humane service employing courageous innovation and executive skill, at sea and on land.

References 1.

Masman EA Hospital Ships of World War II: An Illustrated Reference to 39 United States Military Vessels (Jefferson, NC: McFarland & Co; 1999)

2.

Underwood EA. Naval Medicine in the Ages of Elizabeth and James. Ann R Coll Surg Engl 1947 1(3):115-136

3.

International Committee of the Red Cross. Hospital Ships. Ch 3 in Convention (II) for the Amelioration of the Condition of Wounded, Sick and Shipwrecked Members of Armed Forces at Sea. Geneva, 12 August 1949.( Geneva: ICRC;2005) <http://www.icrc.org/ihl.nsf/ COM/370-580026?OpenDocument> viewed 8 Sep 2011

4.

Hall S. Last hours of the Ice Man. National Geographic, July 2007

5.

Muller W et al. Iceman’s Origins and Wanderings. Science, 31 Oct 2003: 862-866

6.

The Iceman Reconsidered. Scientific American Special Edition, February 2005, pp. 4-13.

7.

Breasted, J.H. The Edwin Smith Surgical Papyrus (University of Chicago Press:

8. http://www.reshafim.org.il/ad/egypt/timelines/topics/ smithpapyrus.htm 9.

Paré, A., The Apologie and Treatise of Ambroise Paré. New York: Dover Publications, Inc., 1968.

10. Pare A. The Method of Curing Wounds Made by Gunshot. Walter Hamond (Ed) Isaac Iaggard,Barbican,London,1617) 11. Sir James Watt, V-Admiral. The injuries of four centuries of naval warfare. Annals of the Royal College of Surgeons of England (I975) vol 57 12. Hughes R. The Fatal Shore. Chapter 5, The Voyage. Pan Books. 1988 13. Burney F Selected letters and Journals, edited by Joyce Hemlow, Oxford University Press, 1986 14. Jonathan Charles Goddard. The navy surgeon’s chest: surgical instruments of the Royal Navy during the Napoleonic War. J. R. Soc. Med. Apr 2004, 97(4):191-7 15. Ford E. Medical practice in early Sydney. MJA, July 9, 1995 16. Principal Surgeon William Balmain in the Colonial Medical Service. A History of Medical Administration in NSW. 17. Twelve Years with Roosevelt. Ross T. (Vice-Admiral) McIntire. Putnams, 1948. 18. Harry S Truman Library and Museum. Remarks at a luncheon for Vice Admiral Ross T McIntyre. October 30, 1951 19. Oral histories of the 2nd World War. US Naval history and heritage Command. Recollections of LCDR Samuel Robert Sherman, MC, USNR, Flight Surgeon on USS Franklin (CV-13) 20. Naval Ingenuity: A Case Study. Semaphore, Newsletter of the Sea Power Centre Australia Issue 18, Nov 2005 21. O’Connor M, Parrish M. Medicine at Sea: morbidity and mortality on RAN ships. ADF Health September 2004 - Volume 5 Number 2

Seaman Medic Adrian Argall onboard HMAS NEWCASTLE, applies an oxygen mask onto a ‘Casualty’ during a medical training exercise

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personal viewpoint

Strategies for Regulating and Improving the Conduct of Military Physicians Are Courts Martial the Answer? Captain Mike O’Connor AM Introduction Captain O’Connor is the current Editor of ADF Health and a practising obstetrician and gynaecologist. His role in Navy is as the Surgical Professional Liaison Officer and he is responsible for approximately 30 Navy surgeons. Currently CAPT O’Connor is undertaking a PhD in the Law School at Sydney University on Medical Complicity in Torture. He also has extensive experience in medico legal work as an expert witness and is Section Editor for the Journal of Law and Medicine. He currently acts as Chairman of the Patient Care Review Committee at St George Private Hospital (SGPH) in Sydney. Until recently he was Chairman of the Medical Advisory Committee at SGPH. Correspondence: celticdrs@bigpond.com

Most doctors are conscientious and act in considerate manner towards their patients. They put the interests of their patients first and observe the ethics of the medical profession. Those ethics were championed by Hippocrates (1) and included respect for teachers of medicine, holding human life sacred and respecting the confidentiality of the patient. The archaic content of the Hippocratic Oath was modified to form the Geneva Declaration of 1948 and this was adopted by the World Medical Association. Most of the 21 undergraduate medical faculties in Australia and New Zealand nowadays administer some form of oath at graduation (2). That “profession” of an oath embracing ethical ideals is what distinguishes the disciplines of law, medicine and the clergy. Psychological research supports the notion that public commitment to a course of action strongly binds the swearer to that behaviour (3). Occasionally doctors fail to uphold the highest ideals of the profession (code of ethics) and may even fall short of a minimally acceptable standard of professional behaviour (code of conduct). Traditionally the medical profession has jealously guarded its right to self regulation: a tribunal of peers being the usual way that such professional misconduct or unprofessional conduct is managed. Recent scandals such as the Shipman cases (4) in the United Kingdom, the Patel (5) and Reeve (6) cases in Australia have called into question the ability of the medical profession to competently self – regulate. In response to the UK scandals the power of the General Medical Council has been diminished. National Health Service regulators now have statutory authority to investigate and stand down UK doctors accused of wrongdoing. Other means of regulating doctors include the familiar and somewhat foreboding civil professional negligence legal actions. Rarely are doctors in Australia prosecuted for criminal medical negligence however in the last 5 years there have been 3 notable exceptions: the Bundaberg manslaughter cases of Dr Patel (7), the genital mutilation by Dr Graeme Reeves in Bega (8) and a criminal abortion performed by Dr Sulman Sood in Sydney (9). Military physicians are not only subject to civilian regulation but also military law. That provides a unique opportunity to utilise alternate disciplinary measures. In this paper I will describe the range of options available to discipline doctors in

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the ADF and suggest that these are greater than those available to the civilian sector. The deterrent effect of such disciplinary measures in the ADF should result in better compliance with ethical standards of medical practice. I will argue that undergraduate medical training has only a small component of formal ethical training and propose that the current ADF program (Project Achilles) (10) which was developed to augment ethical training for members (11) should include health professionals. Finally, I will analyse selected cases of military courts martial involving ADF doctors and make some recommendations for newer methods of military discipline employing techniques developed from psychological research.

Examples of Courts Martial for International Military Medical Officers: disobedience, technical incompetence. Captain Howard B Levy was a young dermatologist who was commissioned as a reserve officer US Army Medical Corps .Following his residency he was then posted to Fort Jackson in 1965. He refused an order to teach dermatology to aidmen in the Special Forces as part of his campaign against the Vietnam War. He was not a conscientious objector but vehemently opposed the Vietnam War. He was charged with disobeying a lawful order; attempting to promote disloyalty and disaffection amongst the troops and making intemperate, defamatory, provoking and disloyal statements to Special Forces personnel whilst in uniform. He was found guilty by a court martial and sentenced to three year’s hard labour in 1965 (12). His attempt to claim conflict between his medical ethics and the Army order in defence was denied by the Presiding Officer, Colonel Brown, because ‘the ethical precepts of a physician are not protected by existing law’(13). A notable US Navy court martial involved a cardiothoracic surgeon, CMDR Donal Billig, who was found guilty of manslaughter by a Navy court martial comprised of 9 members of whom 4 were health professionals including 3 doctors and one nursing officer. He was given a custodial sentence (14). Billig, the former head of cardiothoracic surgery at Bethesda Naval Hospital, had been dismissed from two previous appointments and had not performed open chest surgery in nearly six years before entering the Navy in 1982. Three retired servicemen, who had coronary artery grafts performed by Billig, died postoperatively in 1984. Dr Billig had vision impairment. Billig was charged on five counts of involuntary manslaughter resulting from surgical mistakes and poor judgment in the operating room (15). Five other Navy medical officers were disciplined including the Commander of Bethesda Naval Hospital and the commanding officer of the Naval Health Sciences, Education and Training Command at Bethesda at the time. These two senior officers were censured by the Navy Secretary ‘because of their involvement in the improper credentialing of Dr Billig’. The previous Director of Surgical Services at Bethesda, who directly supervised Dr Billig, was also court martialled. The other two officers were charged with withholding professional information about the ‘‘physical and professional unsuitability’’ of Dr. Billig (16). These recriminations against five other officers including a general court martial were part of a new campaign to hold commanders responsible for doctors under their supervision (17). In 1988, a United States Navy-Marine Corps Court of

Military Review set aside Dr Billig’s conviction because they were not ‘convinced beyond a reasonable doubt that the deaths that formed the basis of the appellant’s conviction were due to any negligence, simple or otherwise, on his part’(18). In the United Kingdom on the 13 April 2006, Flight Lieutenant Malcolm Kendall-Smith, a 28-year-old Medical Officer with the Royal Air Force (RAF).was court-martialled and sentenced to 8 months in prison for a series of offences that resulted from his refusal to serve in Iraq. Defence counsel, Philip Sapsford QC, argued that the defendant believed there was no lawful reason for UK forces to enter Iraq, as Iraq had not attacked the United Kingdom. FLTLT Kendall was also ordered to pay £20 000 from his personal savings towards the defence costs, and dismissed from the service (19).

Courts Martial of ADF Doctors: disobedience, sexual misconduct, violence, substance abuse, absent without leave. A study of such cases was undertaken using anecdotal information supported by information available through the National Archives. Whilst this list is unlikely to be complete (20) the details of those cases which could be identified have been tabulated. Basically they fall into six categories: inappropriate sexual conduct involving patients, substance abuse, assault,insubordination, absent without leave and failure to obey a lawful order. One RAN medical officer was removed from the medical register by the Medical Board after being found guilty of surgically treating sailors beyond his capabilities. Another Army medical officer who assaulted a fellow officer in 1966 was the subject of an internal Army investigation and lost 12 year’s seniority but did not face court martial. Recently the authority of the new Australian Military Court under the Australian Constitution was successfully challenged in the High Court (21).The Federal government responded quickly by reinstating the previous system of Service-based tribunals, namely Courts Martial (22). Under the previous ADF Court Martial system a member would be charged in relation to an alleged offence, say by his/her Commanding Officer and if of a minor nature, the matter could be heard by either a Subordinate Summary Authority (SUBSA) or a Summary Authority (SA) (usually either an Executive Officer (SUBSA) or Commanding Officer (SA) depending on such criteria as rank and the nature of the offence). If the charge was more serious or the member charged were Leading Seaman rank or above and so elected, then the matter could be heard by a Court Martial or Defence Force Magistrate depending upon the nature of the charges being brought. When the AMC was established in October 2007, the intention was to simulate civilian legal process, especially in relation to more serious and complex offences. After investigation by the relevant Service Police, the matter would be referred to the Director of Military Prosecutions (DMP), an entity independent of the ADF and similar to the civilian equivalent, the Director of Public Prosecutions. The DMP would then, if in agreement, prosecute the ADF member and bring the matter before the AMC. The AMC was judicially independent from the Service chains of command and executive. It replaced and modernized the previous system of trial by either Courts Martial (military line officer presiding with panel members

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and a Judge Advocate) or Defence Force Magistrates (an experienced Legal Officer appointed pursuant to the Defence Force Discipline Act 1982 (C’th) (DFDA). The AMC was presided over by a Military Judge with provision for trial by a Military Judge and Military Jury or Military Judge alone (23). The general principles and laws of criminal responsibility as provided for within the Criminal Code (C’th) applied in respect of Service offences prosecuted before the AMC. The onus and standard of proof in disciplinary proceedings before the AMC were generally the same as in proceedings before a civilian court. Trials with a Military Jury were akin to a civilian jury trial (24). Following the successful challenge to the authority in the High Court in 2009, the system of military justice has reverted to the Service-based courts martial. However the independent DMP still has the responsibility of assessing each charge and then prosecuting the matter before either a Restricted Court Martial or a General Court Martial (the diffence between the two being the number of members on the Board and the nature of the charges being tried). The advantage of the DFDA is that it has extraterritorial jurisdiction thus allowing prosecution and punishment of defence members or defence civilians in relation to offences committed overseas (25). Table 1.ADF medical officers court martialled Year

Service

Charge

Conviction

Penalty

1963

Navy

Failure to obey a lawful order

Yes but overturned on appeal

Nil

1967

Navy

Intoxicated on duty

Yes

Dismissal from Service

1975

Navy

Absent from duty without leave

Yes

Reprimand

1981

Navy

Substance abuse & theft of a controlled substance

Yes

Dishonourably discharged

Navy

Sexual misconduct

Yes

Dishonourably discharged

1965

Army

Failure to obey a lawful order

Yes

Imprisonment & Fine (ROSO)

1966

Army

Failure to obey a lawful order

Yes

Imprisonment & Fine (ROSO)

1985

RAN

Absent from Duty

Yes

Dismissed from Service

2011

Army

Insubordination

In progress

No result

Where ADF doctors have breached standards of professional conduct towards patients, the tendency is for those cases to be referred to civil regulators. An example of that involved the recent case of the Medical Board of West Australia v Dr Doug McKenzie (26). In that case the alleged breach of patient confidentiality had occurred on Commonwealth territory at a Navy establishment. A finding of “gross carelessness and improper conduct” was made against the medical officer who had, according to the Board, “improperly referred [a senior

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officer] to a psychiatrist in the absence of any symptoms” and “acted against [the officer’s] trust and confidence” when he conveyed his concern about the officer’s mental state to her Commanding Officer. McKenzie was reprimanded and fined $10,000 (27). Even if, for example, an ADF doctor were charged with breaching a Commonwealth criminal statute such as complicity in torture then it is likely that this matter would be heard in a civil criminal court.

The utility of Courts martial for disciplining military doctors But is court martial the best means of dealing with military physicians serious misbehaviour? A court martial is triggered when the alleged offence occurred on military land during the performance of the member’s military duties. The penalties which can be imposed are fourfold: incarceration, fines, loss of seniority and dismissal from the ADF. One of the trenchant criticisms of court martial processes has been the lack of adequate legal knowledge and expertise enjoyed by some of the panel of adjudicators. For example military commanders who frequently sit in judgement have little legal training. If a medical officer were to be court martialled then justice would only be served if the court empanelled officers with a medical training and experience. Decisions may be based more on deeming the misbehaviour dishonourable to the parent Service than finding objective evidence of fault. Attempts have been made to address those concerns by appointing civilian judges to preside at courts martial (28), establishing a civil court of appeal (29) or bypassing the military justice system completely (30). However the view of the Joint Health Commander (31) is that a court martial should be only the last resort in a range of attempts to regulate medical behaviour. He favours alternative means which rely on reward for good behaviour rather than punishment for poor behaviour. This view is shared by Ayers and Braithwaite: in Responsive Regulation they assert that: ‘the trick of successful regulation is to establish a synergy between punishment and persuasion’ (32). It may be that this ADF system of awards and commendations has been hitherto underutilised as a means of encouragement.

Shaming as a Disciplinary Measure Assertions that doctors are very fearful of loss of reputation amongst their colleagues are convincing (33). Witness the many examples where doctors have applied to medical tribunals to have their name suppressed. The use of shaming as a means of deterrence for medical misbehaviour has been explored in the United Kingdom (34). The arguments against deliberate ‘shaming” as a punishment include that shaming involving adverse publicity is automatic as a consequence of civil medical negligence litigation; that shaming removes a doctor’s right to privacy and that the exposure resulting from public shaming cannot be controlled. There are also doubts that defiant recalcitrant doctors would regret their misbehaviour and could actually ignore any adverse publicity and loss of peer esteem. Shaming however in a military environment has the potential to be a powerful weapon against professional misbehaviour. For example demotion as a punishment is immediately obvious

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as a change in worn rank insignia. Equally loss of seniority is a serious blow to the career of a military doctor be they Permanent or Reservist. There is strong competition for promotion and loss of seniority would in most cases impair the career of any doctor so disciplined.

Nudging as a means of controlling medical behaviour. Cass Sunstein, a Chicago law professor, outlined his theory of “nudging” or “liberal paternalism” (35) whereby ‘good’ choices could be encouraged. For example, healthier choices for students’ lunches at the school canteen are enhanced by making those items more visible and accessible on the shelves. Similarly, software purchasers can be encouraged to download the ‘best’ version of software by making that version the default .There may be aspects of nudge theory which could be adapted to encouraging moral and ethical choices by ADF doctors. By substantially increasing the volume of ethical training, military doctors would be more likely to choose an ingrained ethical decision over any lesser alternative. This would also fit in with the notion of automatism (36) whereby there is a shift from controlled decision making to automatic processing. Because the learner can no longer verbalize intended behaviors or processes, automatization enables task accomplishment without conscious monitoring and enables concurrent performance on additional tasks (37).

Ethics Training for Doctors Formal ethics training for medical undergraduates in Australia is short and variable (38). For example at Sydney University there is a compulsory 2 day module in Year 1 whose intent is for students ‘to be able to demonstrate commitment to compassionate, ethical professional behaviour and the ability to work cooperatively as a member of a team accepting and providing leadership as appropriate. (39).Ethics training for medical undergraduates is obviously no better in the US. ‘Doctors who have Hippocratic ethics have them in spite of medical education, not as a result of it’ (40). There is evidence that an individual’s ethical and moral viewpoints can be changed in adult life (41): Socrates (42) was of that opinion 2,500 years ago (43). In the 1980’s the Harvard psychologist Lawrence Kohlberg identified moral development

beyond the conventional level whereby individuals adopt the ethical and moral norms of their peers. He showed that a higher level of moral development (‘post-conventional’) was possible. That involved reasoning which took account of the universal principles of human rights, justice and welfare. Kohlberg discovered that when his subjects took courses in ethics and these courses challenged them to look at issues from a universal point of view; they tended to move upward through the levels (43). That strategy is currently being developed in the ADF through Project Achilles. Given that medical undergraduate ethical teaching is brief and lacks any specific military component, it is recommended that Permanent and Reservist medical officers are exposed to this moral and ethical teaching at several points in their career. There are anecdotal reports of ethical dilemmas involving medical management of prisoners during deployments. These support the notion that doctors and other health professionals should receive military-specific ethics training in addition to pre-deployment training in International Humanitarian Law.

Making correct ethical decisions under stress. Stress can be defined as a condition occurring when environmental demands are in excess of available resources and lead to undesirable physiological, psychological, behavioural and social consequences (44). There is controversial evidence that under stressful conditions, decision making may be impaired (45, 46). Salas cites the case of an Iranian Airbus shot down by the USS Vincennes in July 1989. Two hundred and ninety passengers and crew including 60 children perished in the Strait of Hormuz (47). The U.S. government believed the incident may have been caused by a psychological condition amongst bridge crew of the guided missile cruiser who were under extreme stress at the time. So-called ‘scenario fulfilment’ is a mind-set which encourages personnel to carry out a training scenario, believing it to be reality while ignoring sensory information that contradicts the scenario. In this case the scenario was an attack by a F14 Tomcat military aircraft (48). This tragedy prompted a seven year research program called Tactical Decision Making under Stress (TADMUS). An analysis of the decisions made by USN Vincennes watch-keeping officers, who were working at a high tempo in very stressful conditions, led to the conclusion that combat stress was the core reason for a poor targeting decision in that case. The goal of TADMUS was to develop training, simulation, decision

Operation Catalyst Photo by: CPL Michael Davis Major Christopher Cunneen, the Overwatch Battle Group (West)-4 Doctor, treats an Iraqi man at the Al Islah medical centre during the Medical Civil Action Program. TITLE: Medics assist at Al Islah Gallery Number 2008-S0485

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support, and display principles that would help to mitigate the impact of stress on decision making (49).

Training for stressful events. Unless sound decisions are learnt so comprehensively that they become automatic (50) then immediate responses in conditions of extreme stress may be ill considered and lack a full consideration of all the relevant factors. There are five consequences of stress on cognitive thinking (51): 1. The absorption of newly presented information is patchy or selective and certainly not comprehensive 2. Short term memory is impaired 3. Automatic responses ,regardless of their previous success, are likely because of pressures of time (52) 4. Natural tendencies to ‘revert to type’ and employ traditional solutions operate 5. The ability to use simulation thought processes is lost (53) These impairments in learning and memory are probably caused by the action of high stress-related glucocorticoid levels on the hippocampus (54). At its best, decision making occurs when all relevant information is processed and assimilated in an objective manner and all alternatives are canvassed before reaching a decision. That is termed ‘vigilant’ decision making. In ‘hypervigilant’ decision making, typically under stressful conditions, information is processed in a selective non-systematic manner; data is rapidly evaluated; alternative decisions are not fully explored and decisions are reached rapidly without sufficient review or reappraisal (55). Stress induced impairments in learning and memory are just as likely to affect doctors who need to make rapid decisions in combat. One solution is for those medical staff is to receive ethical teaching which is so comprehensive and frequent that it becomes ‘second nature’ to make sound decisions which conform with ADF standards. That ethical training should include theoretical teaching in the classroom as well as simulation training in stressful scenarios. There may be value in introducing a form of ‘stress inoculation training’ (56) (SIT) whereby anxiety is reduced by lowering heightened arousal and altering anxietyladen thoughts and images. Coping strategies taught using this SIT strategy include recognizing negative anxious self –dialogue and replacing those with positive self-statements, images and behaviours (57). However stress inoculation training needs to be specific to the anticipated stress.

Conclusions. Regulating ADF doctors is best achieved by a reward system for exemplary behaviour. Persuasion is the preferred method of regulation: punishment should be reserved for those who are unmoved by persuasion (58). Probably insufficient attention has been paid to the use of awards, commendations and promotion as tools to reward high achievement in ethical conduct. Courts martial have been rarely used to discipline ADF medical officers and there are strong arguments why that method of control is inappropriate for clinicians. Where the errors are administrative rather than in clinical care, then court martial may be appropriate. This might involve ADF Health | Vol 12 No. 1 | 2011

situations where senior medical executives fail to adequately supervise clinicians. ADF medical officers, like other service personnel, are at times subject to stressful situations where clear judgement and decisive actions are required. Nowhere is that more likely than when medical officers are in combat. Recognising and planning for those contingencies should include predeployment training not only in International Humanitarian Law but also military ethics. That ethical training needs to be so substantial that correct ethical choices become the default option for our medical officers on deployment. They should be made aware of the potential for poor judgement and decision making under stress. Stress inoculation training does seem to have value but it needs to be specific to the anticipated stressors. Edmund Pellegrino, Emeritus Professor of Medicine and Medical Ethics at Georgetown University, Washington, DC identifies a key difference between military physicians and other military personnel: ‘The military physician…is distinguished…. by his engagement in a special kind of human relationship that …demands a certain level of moral commitment. That commitment must be the determinant of the physician’s conduct even in the extraordinary circumstances of national defense and war….. The good of the patient is, as always, the gold standard of moral propriety (59).

Acknowledgments LCDR Steve Rayner (Navy psychologist) and LCDR Stuart Lowe (Navy legal officer) provided technical assistance for this paper.

References. 1.

Smith WD (ed.) Hippocrates: Pseudoepigraphic Writings. New York: EJ Brill; 1990.

2

O’Connor M .Codes of Professional Conduct for ADF Military Physicians: evenomating the serpent? J Law and Med 2010 18:103-123.

3.

Cialdini RB. The Psychology of Persuasion. New York: Harper-Collins; 2007.

4.

The Shipman Inquiry_6th Report <http://news.bbc.co.uk/2/shared/ bsp/hi/pdfs/27_01_05_shipman_6threport.pdf > viewed 20 Aug 11

5.

R v Patel [2010] QSC 233 (1 July 2010) <http://www.austlii.edu.au/ au/cases/qld/QSC/2010/233.html > viewed 28 Jul 11

6.

R v GSR (3) [2011] NSWDC 17 (15 March 2011) <http://www.austlii. edu.au/au/cases/nsw/NSWDC/2011/17.html >viewed 28 Jul 11

7.

R v Patel [2010] QSC 233 (1 July 2010)

8.

R v GSR (3) [2011] NSWDC 17 (15 March 2011)

9.

R.v. Sood [2006] NSWSC 1141

10. Unkles J ‘New project to look at ethics’ Navy News 1 Apr 2010 <http:// digital.realviewtechnologies.com/default.aspx?iid=34734&startpage= page0000014> viewed 28 July 11 11. 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 2005 Senate report on the effectiveness of Australia’s military justice system highlighted areas of concern which need to be addressed in the professional joint military educational environment’ <http://www.defence.gov.au/adc/ centres/cdle/research.html> viewed 28 Jul 11 12. Parker v Levy No. 73-206 Supreme Court of the United States 417 U.S. 733 <http://www.bc.edu/bc_org/avp/cas/comm/free_speech/ parker.html> viewed 24 Aug 11

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13. Langer E. (1967) The Court-Martial of Captain Levy: Medical Ethics v. Military Law. Science, New Series 156:1346-1350. 14. Murphy J, Duffy M. Medicine: A Naval Surgeon in the Dock. Time Magazine 1986, March 3. http://www.time.com/time/magazine/ article/0,9171,960848,00.html viewed 28 Jul 11 15. Murphy J, Duffy M. op cit 16. Boffey PM .Navy Heart Surgeon Charged in 4 Patient Deaths.New York Times 1985 June 20. < http://www.nytimes.com/1985/06/20/us/navyheart-surgeon-charged-in-4-patient-deaths.html?pagewanted=print> viewed 24 Aug 11 17. Boffey PM .op cit 18. United States v Donal M Billig, 119 24 6838, Commander (O-5), U.S. Naval Reserve. United States Navy-Marine Corps Court of Military Review 26 M.J. 744(1988) <http://www2.newpaltz.edu/~zuckerpr/ cases/billig.htm> viewed 25 Aug 11 19. Gulam H, O’Connor M. Selective conscientious objection: the court martial of Flight Lieutenant Malcolm Kendall-Smith, RAF ADF Health 2006 7(2):68-72.

39. Sydney University, Faculty of Medicine, Undergraduate Units of Study, GDMP1013 Population Medicine 1, http://www.usyd.edu.au/ handbooks/medicine/06_UG_UoS.shtml 40. Lunstroth J. Torture and the Regulation of the Health Care Professions in Allhof F (Editor) Physicians at War. The Dual-Loyalties Challenge. Springer Science & Business Media BV 2008 at 128. 41. Lawrence Kohlberg. (1984) Essays on Moral Development Volume II The Psychology of Moral Development .426. 42. Velasquez M, Andre C, Shanks T, Meyer MJ.Can Ethics be Taught? Markkula Center for Applied Ethics. Santa Clara University.Ca. Issues in Ethics V1 N1 (Fall 1987) <http://www.scu.edu/ethics/practicing/ decision/canethicsbetaught.html > viewed 29 Jul 11 43. Velasquez, Andre, Shanks, Meyer-op cit 44. Salas E, Driskell JE, Hughes SS. The Study of Stress and Human Performance. Lawrence Erlbaum Associates: New Jersey; 1996 45. Salas, Driskell, Hughes_op cit

20. For example, the National Archives has mistakenly coded as “Medical” defendants from Medium Artillery regiments.

46. Klein G, The Effect of Acute Stressors on Decision Making in Stress and Human Performance Driskell JE and Salas E (Editors) Psychology Press, New York.1996

21. Brendan Nicholson. Military Courts in Tatters. The Age, Melbourne.2009 27 Aug. <http://www.theage.com.au/national/ military-courts-in-tatters-20090826-ezr7.htm>l viewed 24 Aug 2011

47. Cook NJ, Stories of Modern Technology Failures and Cognitive Engineering Successes”, CRC Press, 2007, PP77

22. The Military Justice (Interim Measures) Act (No. 1) (C’th) 2009 23. Australian Defence Force Australian Military Court – Fact Sheet <http://www.defence.gov.au/mjs/resources/AMC%20fact%20sheet. pdf> viewed 1 Sep 11 24. AMC Fact Sheet-op cit 25. Defence Force Discipline Act 1982 (C’th) http://www.austlii.edu.au/au/ legis/cth/consol_act/dfda1982188/s9.html viewed 1 Sep 11 26. Nisselle.P ‘Can you tell? Should you tell?’ ADF Health 2005 6:9-11. < http://www.defence.gov.au/health/infocentre/journals/ADFHJ_ apr05/ADFHealth_6_1_09-11.pdf> viewed 28 Jul 11 WA Medical Board v McKenzie Unreported, Medical Board of Western Australia, No 1501-7, 20 July 2004 27. ‘Labor criticises legal fees in navy case’ 9 News 2006, June 1 http:// news.ninemsn.com.au/national/104545/labor-criticises-legal-fees-innavy-case viewed 30 Aug 11

48. The Other Lockerbie, BBC, 2000 17 April < http://www.abc.net. au/4corners/archives/2000a_Monday17April2000.htm> viewed 23 Aug 11 49. Cannon-Bowers JA. , Salas, E (Editors). Making decisions under stress: Implications for individual and team training. Washington, DC, US: American Psychological Association. (1998). 50. Kraiger K,Ford KJ,Salas E. Application of Cognitive,Skill-Based ,and Affective Theories of Learning Outcomes to New Methods of Training Evaluation.J Appl Psych 1993 78:311-328. 51. Driskell JE, Salas E. (1996) Stress and Human Performance Mahwah, NJ: L Erlbaum. 52. Lehner P, Seyed-Soloforough M, O’Connor MF, Sak S, Mullin T. (1997) Cognitive Bias and Time Stress in Team Decision Making. IEEE Transactions on Systems, Man and Cybernetics Part A Systems and Humans 27:698-703.).

32. Ayers I, Braithwaite J. Responsive Regulation: Transcending the deregulation debate. New York: Oxford University Press; 1992 at 25

53. Janis I,Defares P,Grossman P(1983)Hypervigilant Reactions to Threat in H Selye (Ed) Selye’s Guide to Stress Research. Vol 3 1-42.NY Van Nostrand Reinhold; Janis I Mann L (1977) Decision Making. NY: Free Press. Keinan G (1987) Decision Making Under Stress: Scanning of Alternatives under Controllable and Uncontrollable Threats.J Pers Soc 52:639-644 Psych, Streufert S, Streufert SC (1981) Stress and Information Research in Complex Decision Making: Effects of Load and Time Urgency. (Technical report No 4) Arlington, VA: Office of Naval Research, Walton RE, & McKersie RB, (1965) A Behavioural Theory of Labor Negotiation: An Analysis of a Social Interaction System. New York: McGraw-Hill.; Wright P (1974) the Harassed Decision Maker: Time Pressures, Distractions and the Use of Evidence.J Appl Psych 59:555561.

33. Davidoff F. Shame: the elephant in the room. Qual Saf Health Care. 2002 11:2-3.

54. McEwen BS, Sapolsky RM. Stress and Cognitive Function. Current Opinion in Neurobiology 1995 5:205-216.

34. Bismarck M, Paterson R. Naming, blaming and shaming. Med Law 2006 25(1):115-125.

55. Johnston JH, Driskell JE, Salas E.Vigilant and Hypervigilant Decision Making.J Appl Psych 1997 82:614-622.

35. Thaler RH, Sunstein CR Nudge: Improving Decisions About Health, Wealth and Happiness New York: Penguin Books; 2006.

56. Meichenbaum DH, Deffenbacher.Stress Inoculation Training.The Counselling Psychologist 1988.16:69-90.

36. Kraiger K, Ford JK, Salas E, Application of Cognitive, Skill-Based, and Affective Theories of Learning Outcomes to New Methods of Training Evaluation.J Appl Psych.1993 78:311-328.

57. Meichenbaum DH, op cit.

28. Civil judges are used in the British Army, Royal Air Force and in the New Zealand Defence Forces.MAJGEN L Roberts-Smith RFD. Judge Advocate General, Australian Defence Force Submission to Senate Inquiry on Effectiveness of Australia’s Military Justice System 16 Feb 2004 < http://www.defence.gov.au/jag/docs/submission_mji.pdf> viewed 28 Aug 11 29. Roberts-Smith op cit 30. Roberts-Smith op cit 31. MAJGEN Paul Alexander. Joint Health Commander ADF Personal Communication 4 Sep 2010.

37. Shiffrin, R. M, Dumais, S. T. (1981). The development of automatism. In J. R. Anderson (Editor.), Cognitive skills and their acquisition (pp. 111-140). Hillsdale, NJ: Erlbaum. 38. O’Connor MC. Codes of Professional Conduct for ADF Military Physicians: evenomating the serpent? J Law and Medicine 2010 18:103-123.

58. Smith RG. Health care, crime and regulatory control. Sydney: Hawkins Press; 1998. 59. Pellegrino W.The Moral Foundations of the PatientPhysician Relationship: The Essence of Medical Ethics in Beam TE, Sparacino LR (Editors) Military Medical Ethics Vol 1 Washington, The Borden Institute; 2003. < http://www.bordeninstitute.army. mil/published_volumes/ethicsVol1/Ethics-ch-01.pdf> viewed 2 Sep 11

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the sir william williams author’s prize

Major Michael Tyquin

T

he Sir William Williams Prize has been established to encourage the research, writing and publication of high quality, original papers from among junior ranks of the ADF’s health and allied professions. The prize will assist the work’s wider dissemination among the Defence health community. The value of the prize is $1,000. The award will be subject to ongoing review by the senior ADF health commander. Authors who are junior officers (i.e. those at or below the rank of Lieutenant Commander/ Major/Squadron Leader), NCOs or Other Ranks are eligible for consideration. Candidates must therefore be full- or part-time members of the ADF at the time of the paper’s submission. The prize winner will be notified in the first quarter of each year and their name/s publically acknowledged in the first issue of the ADF Health Journal that year. The evaluation committee will be formed of members of the ADF Health Journal editorial board. The committee’s decisions will be final. The prize will be awarded on the basis of: • the originality of the paper submitted; • the potential for it to influence or inform ADF health policy or practice; and • the extent to which it could reasonably be assumed that the paper will assist in the future delivery of improved prevention, management or remediation of health and related illness and injury among ADF members. Where there is no outstanding candidate/s the prize will be held over until the following year.

Sir William Williams KCMG, CB, KStJ There is a strong argument for placing Surgeon-General Sir William Williams at the centre of Australia’s military medical history. Born in Sydney on 20 July 1856, Williams was educated at Sydney Grammar School before graduating at London University College Medical School at 24 years of age. He was subsequently appointed Principal Medical Officer for a small contingent of troops New South Wales deployed to the Sudan in 1885. After returning to Sydney he later established an ambulance corps to support that colony’s 3,000 soldiers. He began to develop what was to become a life-long interest in training. He frequently conducted examinations of both officers and Other Ranks. Addressing a United Services

ADF Health | Vol 12 No. 1 | 2011

Institute meeting in 1893 he suggested a motto for the New South Wales Army Medical Corps, one which was subsequently adopted by the Australian Army Medical Corps (now the RAAMC). He proposed ‘Paulatim’, a Latin word that reflected the short history and subsequent growth of the corps up to that time – ‘little by little’. An enthusiastic proponent of federation and of the army and navy, he was a frequent contributor to pre-federation Australian medical and military literature and rarely ignored the opportunity to speak on these issues. He believed that the British Army’s medical organisational model was too large and elaborate for the colonial medical services and pointed out that unless Australia’s colonial units followed some definite line of organisation, personnel, equipment, and training, chaos and confusion would follow in the event of a joint mobilisation. Keenly aware of soldiers’ welfare Williams argued for lighter, better fitting uniforms of the khaki type, and suggested that the red and blue tunics then worn be retained for ceremonial purposes only. During the Boer War Williams was appointed the Principal Medical Officer of Sir Archibald Hunter’s force of almost 35,000 troops – a considerable responsibility for a colonial officer and recognition of his outstanding drive and organisational abilities. He is therefore a candidate for holding the first Anzac command. In the field he was a strong believer in mobility and worked to ensure that Australian ambulance units could deploy almost anywhere at short notice by using special lightweight carts. Williams was also a bitter enemy of military red tape. Between 1905 and 1915 he served as member of the Military Board which was responsible for administering the Australian Military Forces. He was elected vice-president of the XVIII International Congress of Medicine in August 1913. Williams was an early and consistent supporter of army nursing and was a key player in the establishment of an army nursing service. He worked tirelessly to prepare the medical services so they could support any large scale deployment of Australian military forces. He did this through standardising equipment and training, instituting high recruiting standards and recruiting suitable young doctors into the reserves. By 1915 Williams’ best years were behind him, and it fell to younger men, such as Victoria Cross winner surgeon Neville Howse, to continue to keep the interest of Australia’s health services before both the Government and senior commanders. But Williams left an outstanding legacy, one that is maintained today by the various health branches of the ADF. Williams died on 10 May 1919 was given a full military funeral and was buried in Melbourne’s Brighton cemetery.

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letter to the editor

The written fellowship examinations for the RACGP can now be done online whilst on overseas deployments

Twice a year the Royal Australian College of General Practitioners conducts examinations to attain the qualification of Fellow of the Royal Australian College of General Practitioners. Up until now most regular ADF medical officers have reported significant difficulties in completion of GP training in a timely fashion. This appears to be due to conflicts between ADF operational requirements, and the need to undertake GP training and examinations in reliable and stable personal circumstances during examination periods. In 2011, for the first time, the RACGP offered the written fellowship examinations online. In July 2011, I undertook the two written components of the fellowship examinations whilst deployed as Regimental Medical Officer, Force Support Unit Four, at Multinational Base Tarin Kot, Afghanistan. A number of arrangements were necessary in order to undertake the examination in Afghanistan. Support from

the RACGP to undertake the examination remotely was obtained by lobbying from my training provider GP Synergy and personal direct contact. The RACGP kindly agreed to provide the political and logistical support to undertake the examination online overseas. Special consideration was granted on the basis of logistic difficulties and remoteness, allowing for reimbursement of examination fees in the event of misadventure (e.g. attack on base). The examination was undertaken on the welfare internet with support of the Force Communications Unit, invigilated by the Officer Commanding Force Support Team Tarin Kot. The software ran flawlessly for the duration of the examination. The software utilised captured web browser technology, but is not currently authorised on the Defence Restricted Network (DRN). An important next step for future ADF registrars would be gaining approval to run the examination software on the DRN. This is the first time the RACGP fellowship examination has been completed in this way for an ADF registrar, and the first time conducted outside of Australian territory online by any candidate. It opens the door for ADF registrars to undertake the written examination on operational deployment, on ships at sea, in support areas, on exercise and in other remote locations. This new examination option will likely decrease the difficulties that future ADF medical officers face in completing RACGP fellowship requirements. Continued high level cooperation between the ADF, GP training providers and RACGP will ensure that the flexibility and benefits made accessible by this development will be available for ADF registrars in the future. David J Heslop PhD (Medicine) MBBS BSc (Adv) Hons I Captain. RMO, 1st Health Support Battalion Manunda Lines Holsworthy Barracks NSW 2173 david.heslop@defence.gov.au

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ADF Health | Vol 12 No. 1 | 2011

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