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How do we fight COVID-19? Military Key messages

►► As part of the national effort, the medical actions in the war against the French Military Medical Service was committed to the fight COVID-19 pandemic in France against COVID-19, involving all its departments. 1,2 3 3 1,2 4 Pierre Pasquier, A Luft, J Gillard, M Boutonnet, C Vallet, ►► Within a global medical system, J-M­ Pontier,5 S Duron-­Martinaud,3 A Dia,6 L Puyeo,7 F Debrus,7 innovative, dedicated interventions 2,8 9 2,10 2,11 brought together adaptive solutions B Prunet, S Beaume, G de Saint Maurice, E Meaudre, to issues encountered in the C Ficko,2,12 A Merens,2,12 G Raharisson,3 B Conte,13 F Dorandeu,2,14 COVID-19 pandemic. F Canini,2,14 R Michel,2,15 S Ausset,2,15 J Escarment2,16 ►► Unprecedented and unique actions were conducted, including the use of a military intensive care field hospital health management. The French Military Centre ABSTRACT and multiple collective aeromedical for Epidemiology and Public Health provided ’We are at war’, French President Emmanuel evacuations of patients with severe all information needed to guide the decision-­ Macron said in an address to the nation on acute respiratory distress syndrome. 16 March 2020. As part of this national effort, making process. Medical centres of the French ►► Dedicated military strategies have the French Military Medical Service (FMMS) Armed Forces organised the primary care for been adopted for the management is committed to the fight against COVID-19. military patients, with the widespread use of of patients in France, as well as in This original report aimed to describe and telemedicine. The Paris Fire Brigade and the overseas military operations. detail actions that the FMMS has carried out Marseille Navy Fire Battalion emergency depart- in the nationwide fight against the COVID-19 ments ensured prehospital management of pandemic in France, as well as overseas. Experts patients with COVID-19. The eight French mili- 9–11 in the field reported major actions conducted by tary training hospitals cooperated with civilian cases were confirmed in France. As the FMMS during the COVID-19 pandemic in regional health agencies. The French military part of the national effort, the FMMS was France. In just few weeks, the FMMS developed medical supply chain supported all military committed to the fight against COVID-19, ad hoc medical capabilities to support national medical treatment facilities in France as well involving all its departments. This report describes (Figure 1) the actions carried health authorities. It additionally developed as overseas, coping with a growing shortage copyright. adaptive, collective en route care via aero- of medical equipment. The French Armed out by the FMMS in the fight against the COVID-19 pandemic in France, as well as medical and naval units and deployed a mili- Forces Biomedical Research Institute performed overseas. tary intensive care field hospital. A COVID-19 diagnostics, engaged in multiple research Experts in the field reported the crisis cell coordinated the French Armed Forces projects, updated the review of the scientific following major actions conducted by the literature on COVID-19 daily and provided 1 FMMS during the COVID-19 pandemic Percy Military Training Hospital, French Military Health expert recommendations on biosafety. Finally, Service, Clamart, France in France. 2 Ecole du Val-­de-Gr­ âce French Military Medical even students of the French military medical http://militaryhealth.bmj.com/ Academy, Paris, France academy volunteered to participate in the fight 3Direction Centrale du Service de Santé des Armées, against the COVID-19 pandemic. In conclusion, COVID-19 CRISIS RESPONSE CELL OF Paris, France in an unprecedented medical crisis, the FMMS THE FMMS SURGEON GENERAL OFFICE 4Service Médical de la Force d’Action Navale, French engaged multiple innovative and adaptive As early as February 6, 2020, the Military Health Service, Toulon, France FMMS Surgeon General Office initi- 5Cephismer, Centre d’Expertise Plongée pour la Marine actions, which are still ongoing, in the fight Nationale, French Military Health Service, Toulon, France against COVID-19. The collaboration between ated a COVID-19 crisis cell to coordi- 6 Centre d’épidémiologie et de Santé Publique des military and civilian healthcare systems rein- nate actions related to the COVID-19 Armées, French Military Health Service, Marseille, France pandemic.12 13 The purpose of this response 7 forced the shared objective to achieve the goal Direction de la Médecine des forces, French Military cell was to ensure continuity and ongoing Health Service, Tours, France of ’saving the greatest number’. 8Emergency Department, Brigade de Sapeurs-­Pompiers adaptation of military medical support de Paris, Paris, France while responding to the public health on September 24, 2021 by guest. Protected 9Bataillon des Marins-­Pompiers de Marseille, French authorities’ requests for assistance.14–16 Military Health Service, Marseille, France Providing care as close to the front- 10 This twofold challenge involved main- Legouest Military Training Hospital, French Military line as possible is the ultimate mission taining the French Armed Forces opera- Health Service, Metz, France 11 of the French Military Medical Service tional capabilities at home and in overseas Sainte-­Anne Military Training Hospital, French Military 1 2 Health Service, Toulon, France (FMMS). Beyond this primary mission, military operations while ensuring the 12Bégin Military Training Hospital, French Military Health the FMMS makes a significant contribution health of military personnel and limiting Service, Saint-­Mandé, France to the field of public health and the design 13 the spread of severe acute respiratory Direction des approvisionnements en produits de of government risk-­management plans santé des armées, French Military Health Service, syndrome coronavirus 2 (SARS-­CoV-2). Orléans, France intended to deal with health crises and From 6 April, more than 20 000 virtual 3–8 14Institut de Recherche Biomédicale des Armées, French terrorist threats. In the spring of 2020, consultations were conducted.17 The Military Health Service, Brétigny-­sur-­Orge, France COVID-19 spread through France. ‘We 15 use of teleworking enabled military Écoles Militaires de Santé, French Military Health are at war’, French president Emmanuel and medical teams to preserve human Service, Lyon-­Bron, France 16French Military Health Service, Paris, France Macron said in an address to the nation on resources and to conduct all core missions 16 March 2020. ‘The enemy is invisible, of the French Armed Forces, including Correspondence to Prof Pierre Pasquier, Percy and it requires our general mobilisation’. the new COVID-19 French population-­ military training hospital, French Military Health Service, 18 Clamart 92140, France; pasquier9606@​ ​me.com​ By mid-­April, over 100 000 COVID-19 supporting Operation RESILIENCE. In Pasquier P, et al. 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Collective aeromedical evacuations of civilian critically ill patients with COVID-19 8 military training hospitals - 9,268 patients with COVID-19 The French Air Force and the FMMS - 2,419 hospitalisations Field military intensive care hospital deployed a collective aeromedical evac- - 472 ICU admissions - 47 patients with COVID-19 and ARDS uation (aero-MEDEV­ AC) system. This Telemedicine - > 1000 consultations / day system used a military A330 Airbus, equipped with a resuscitation module for high elongation evacuation (MoRPHEE Module de Réanimation pour Patient à Haute Elongation d’Évacuation) system > 12,000 patients with COVID-19 and ARDS in prehospital setting which transformed the plane into an - Paris fire brigade > 60 Medevac missions for patients with COVID-19 - Marseille navy fire battalion - fixed- rotary-wings, naval ship intensive care unit (ICU) for a long-­ distance aero-MEDEV­ AC of six critically 6 collective ICU aeromedevac 21 22 - patients with COVID-19 and ARDS ill patients (Figure 2). A total of six aero-­MEDEVAC systems transferred 36 patients with COVID-19. The six aero-­ MEDEVAC flights lasted between 52 and 77 min, with distances ranging from 700 to 1080 km. All patients received protec- tive mechanical ventilation. Two patients experienced severe hypoxaemia episodes. No other serious respiratory adverse events occurred, and no life-threatening­ Figure 1 French Military Medical Service's responses to COVID-19. ARDS, acute respiratory event was reported. distress syndrome; ICU, intensive care unit.

Conception and deployment of a 30-bed overseas military operations, the FMMS aeromedical evacuation of all patients military intensive care field hospital in doctrine is based on early damage control presenting with respiratory symptoms or Eastern France resuscitation and surgery, combined with low-­risk factors.20 Furthermore, in just copyright. Following the order of the French presi- early strategic aeromedical evacuations.2 19 few weeks, the FMMS developed ad hoc dent, the FMMS designed a 30-­bed mili- These principles were applied to patients medical capabilities to support national tary intensive care field hospital. In an with COVID-19, intending to limit the health authorities: adaptive en route care unprecedented manner, the Élément Mili- incidence of severe COVID-19 cases in aeromedical capabilities and a military taire de Réanimation du Service de Santé overseas military operations. A strategy intensive care field hospital. des Armées (EMRSSA, field ICU of the was implemented in overseas military FMMS) offered a fully integrative inten-

operations for the systematic, early http://militaryhealth.bmj.com/ sive care system. The EMRSSA joined and supported the Emile Muller hospital in Mulhouse. Prior to the EMRSSA deploy- ment, the Emile Muller Hospital increased the number of available ICU beds from 36 to 62. The EMRSSA offered 30 additional ICU beds. The EMRSSA field hospital aimed to achieve two main objectives: first, to treat critically ill patients with COVID-19-­associated acute respiratory

distress syndrome (ARDS) according to on September 24, 2021 by guest. Protected the best standards of care and, second, to protect caregivers.23 24 Fully equipped with high standard of devices for critical care, three ICU wings were progressively set up.25 26 Figure 3 shows a general overview of the EMRSSA, and Figure 4 displays a view of an EMRSSA ICU wing. In the first 3 weeks, more than 40 COVID-19 critically ill patients were transferred into the EMRSSA. All patients presented with ARDS and required protective mechanical ventilation. Each ICU wing was staffed following appropriate structural and organisational requirements for ICUs.27 28 The protection of the EMRSSA personnel Figure 2 Military collective aeromedical evacuation of critically ill patients with COVID-19. was one of two main objectives of the

2 Pasquier P, et al. BMJ Mil Health Month 2020 Vol 0 No 0 Personal view BMJ Mil Health: first published as 10.1136/bmjmilitary-2020-001569 on 5 August 2020. Downloaded from

FRENCH ARMED FORCES COVID-19 CRISIS CELL IN INTERACTION WITH THE FRENCH MILITARY CENTRE FOR EPIDEMIOLOGY AND PUBLIC HEALTH The COVID-19 crisis cell coordinated the French Armed Forces health management for the COVID-19 pandemic, providing dedicated public health recommendations and proposing adequate strategies to mili- tary and civilian authorities and decision-­ makers. The COVID-19 crisis cell brought together public health experts, in close contact with their counterparts in the field, working at the French Military Centre for Epidemiology and Public Health (Centre d'Épidémiologie et de Santé Publique des Armées). In the context of the COVID-19 pandemic, the French Military Centre for Figure 3 General overview of the military intensive care field hospital. ICU, intensive care unit. Epidemiology and Public Health quickly implemented a daily epidemiological report based on existing information tech- mission. With advising from an infection island to different ICUs in Marseille, nology tools and conducted also epide- control team, the EMRSSA was separated mainland France. On-board­ hospital miological investigations around each into three different zones according to capacities were upgraded and reorgan- case and clusters that occurred within different protection levels: a green zone ised into an ICU for extended transport, the French Armed Forces units. From the (wearing of a surgical mask), an orange with biohazard constraints.30 31 Stan- early stages of the COVID-19 outbreak zone (wearing of an FFP2 mask) and a red dard medical equipment was upgraded, in France, several members of the French zone (wearing of full personal protective including mechanical ventilators, patient Military Centre for Epidemiology and equipment: FFP2 or FFP3 mask, gown, monitors, and point-­of-­care blood gases 29 Public Health were deployed within gloves, eye protection and apron). analysers. The naval medical team was

mobile investigation teams to investigate copyright. reinforced by a civilian-military­ inten- around the suspected COVID-19 military Naval evacuation of civilian patients sivist team, one bacteriologist, four cases reported. Mobile investigation teams certified registered nurse anaesthetists, with COVID-19 performed epidemiological and biological six ICU registered nurses, one imaging The French Navy amphibious assault investigation missions in military units and assistant, and one laboratory assistant. ship Tonnerre was deployed on 22 March military training hospitals. On 17 March The total naval transfer delay was less 2020 to conduct a naval medical evac- 2020, when France moved to the third uation of 12 critically ill patients with than 20 hours. No complications were stage of the outbreak management plan, http://militaryhealth.bmj.com/ COVID-19 from hospitals on the Corsica reported for any of the 12 patients. a call centre run by public health experts was in charge of the daily follow-­up of all the contacts identified within the French Ministry of Defence. The call centre oper- ators asked each of the phone contacts several questions to identify symptoms of COVID-19 and provided them with prevention and self-surveillance­ advice. Simultaneously, the experts from the French Military Centre for Epidemiology

and Public Health provided practical on September 24, 2021 by guest. Protected advice to local military commanders and to military healthcare workers about the necessary actions to prevent the spread of the virus within their units and to manage COVID-19 cases.

Reorganisation of the Department of Armed Forces Medicine for primary care of military patients and continuity of the Armed Forces medical support Medical centres of the French Armed Forces organised primary care for mili- tary patients, including their families, to prevent the risk of SARS-­CoV-2 Figure 4 Inside the military intensive care field hospital. infection. As a result, two medical

Pasquier P, et al. BMJ Mil Health Month 2020 Vol 0 No 0 3 Personal view BMJ Mil Health: first published as 10.1136/bmjmilitary-2020-001569 on 5 August 2020. Downloaded from consultation circuits were established especially in treating clinical COVID-19 from the eight French military training in all military medical centres: one for presentations. hospitals and the Val-de-­ ­Grâce Military patients suspected of being positive for Similar to the Paris Fire Brigade, the Medical Academy proposed a dedicated COVID-19 and a second for patients not Marseille Navy Fire Battalion is a military crisis organisational strategy to the French suspected of being positive for COVID- fire department unit of the navy dedicated Society of Anesthesia & Intensive Care 19. Since 6 April 2020, more than 30 000 to the protection of Marseille, the second-­ Medecine.32 The objective was to increase medical consultations occurred, including largest city in France. From the beginning the number of ICU beds available to serve 9429 ambulatory follow-ups­ for patients of the COVID-19 pandemic, the prehos- the greatest number of patients. New ICU with COVID-19. During the same period, pital medical emergency service of the beds were created outside the perimeter the military medical centres conducted Marseille Navy Fire Battalion adapted its of ICUs: intermediate care units, recovery 22 289 virtual consultations. Telemedicine procedures and ambulance equipment to rooms and even inside operating theatres. emerged as an appropriate way to monitor cope with COVID-19 challenges. Between In each military training hospital, the signs of COVID-19 among contacts of 1 February and April 30, the basic life numbers of ICU beds multiplied between stay-­at-­home patients with COVID-19. support teams of the Marseille Navy Fire 1.5 and 2.0. In response to the mass casu- Fifty physicians, flight surgeons, nurses Battalion managed 1185 patients with alty concerns, military training hospitals and caregivers of the Department of suspected COVID-19, with 125 patients set up ventilation weaning units to remove Armed Forces Medicine participated requiring the intervention of an advanced patients from ICUs while they were still actively in the medical transport of 120 life support team. A total of 1019 patients ventilated, as previously reported for critically ill patients with COVID-19 by were admitted to a hospital and 166 trauma patients.33 Before May 2020, the military aircrafts or helicopters, battle- were discharged. Advanced life support eight military hospitals admitted 9268 ships, trains or ambulances. Moreover, 10 teams transferred 12 patients from the patients, with 2419 hospitalisations, and military critical care teams were trained to airport (aero-­MEDEVAC) and the seaport 472 patients in the ICU. The military reinforce overseas military operations in (navy-­MEDEVAC) to civilian and military training hospitals and, specifically, Bégin the context of the COVID-19 pandemic. ICUs in Marseille, and helped to transfer Military Training Hospital (Saint-Mandé),­ 15 patients from one ICU to another in specialised in the field of infectious the city. Medical teams also contributed disease, conducted dedicated actions: to COVID-19 diagnostic screening in PREHOSPITAL MANAGEMENT OF ►► Diagnostic and treatment of military PATIENTS WITH COVID-19 BY BASIC retirement homes to help the National patients with COVID-19. Health Services; more than 900 residents AND ADVANCED LIFE SUPPORT TEAMS ►► Molecular diagnostic by RT-­PCR for and social workers were involved in this OF THE PARIS FIRE BRIGADE AND THE cluster investigations, epidemiological copyright. MARSEILLE NAVY FIRE BATTALION effort. One medical chemical, biological, surveys, screening before returning to EMERGENCY DEPARTMENTS radiological and nuclear defence expert duty or before deployment in overseas also contributed to the development of The Paris Fire Brigade is a military unit of military operations, and provision of the COVID-19 Marseille Environmental the army whose primary and permanent serological tests. Testing project. The project aimed to role is operational defence of the popu- ►► 24/7 national medical call centre for detect SARS-CoV­ -2 in the environment by lations in the greater Paris area. Between diagnostic and therapeutic advice. performing RT-PCR­ on samples and thus

1 February and 20 April, the Paris Fire ►► Edition of dedicated procedures for http://militaryhealth.bmj.com/ improving decontamination protocols. Brigade basic life support teams cared realisation of nasopharyngeal swab for 9445 patients with COVID-19 in specimen, use of personal protec- the prehospital setting, leading to 6044 EIGHT FRENCH MILITARY TRAINING tive equipment, infection prevention hospital admissions and 3401 discharged HOSPITALS IN ORIGINAL INTERACTION and control, and review of medical at home. In the same period, the Paris Fire WITH CIVILIAN HOSPITAL protocols. Brigade advanced life support teams cared ORGANISATION ►► Deployment of molecular diagnostic tools in French military field labora- for 353 patients with COVID-19 in the The eight military training hospitals are prehospital setting, including 76 severe spread throughout France. The medical tories in overseas military operations. cases requiring a prehospital tracheal director of each one is the FMMS repre- intubation, invasive mechanical ventila- sentative to the regional health agencies, GROWING SUPPORT OF THE FRENCH on September 24, 2021 by guest. Protected tion and ICU admission. These advanced monitoring the interactions between MILITARY MEDICAL SUPPLY CHAIN life support teams participated in 48 public health needs and the military’s The French military medical supply aero-­MEDEVAC of ICU patients hospi- capabilities. The collaborations in Eastern chain is composed of a central office, an talised for COVID-19 ARDS. The Paris France since March 2020 illustrated such institution in charge of purchasing and Fire Brigade operation centre received interactions: the delivery of 20 mechan- payments, two pharmaceutical establish- and processed all the calls transmitted ical ventilators from the French military ments for distribution of health products, from emergency numbers and contributed medical supply chain to the Eastern France an institution specialised in studies, main- directly to the solving of operational situ- Regional Health Agency; the set-up­ of tenance and distribution of medical equip- ations and to a synergy between different aero-MEDEV­ AC for 90 patients from ment, a pharmaceutical drug production services that participated in the crisis civilian ICUs in Mulhouse to other ICUs facility and a dedicated blood transfusion management in the Parisian zone. The in France, Germany, Luxembourg, Swit- centre. Its mission is to acquire health Alerts Processing Centre received more zerland and Austria; and the admission of products, supply medical units on the than 6000 calls per day and engaged the 383 patients in Legouest Military Training national territory, as well as in overseas rescue teams around 1400 times. It acti- Hospital (Metz). In the context of the military operations, and maintain strategic vated and managed the basic advanced life COVID-19 pandemic, and the anticipa- stocks and medical equipment. From 7 support and advanced life support teams, tion of mass casualties in the ICUs, experts March 2020, the French military medical

4 Pasquier P, et al. BMJ Mil Health Month 2020 Vol 0 No 0 Personal view BMJ Mil Health: first published as 10.1136/bmjmilitary-2020-001569 on 5 August 2020. Downloaded from supply chain integrated the French Armed Institute were tasked with assessing the Acknowledgements The authors pay a great tribute Forces COVID-19 crisis cell. Moreover, physiological constraints of several types to the service members of the French Military Medical the French military medical supply chain of modified masks. Some of its biosafety Service who are still engaged in the combat against conducted repeated emergency procure- specialists provided consultations and COVID-19, as well as to those who are deployed ment procedures to face strains on health training for donning and doffing personal in overseas military operations. The authors thank Professor Stéphane Gaudry (ICU, Hôpital Avicennes, protective equipment and obtaining product supplies. The French military Bobigny, France) for his clever review. medical supply chain studied the use of 3D nasopharyngeal swab specimen.34 They delivered biosafety recommendations for Contributors PP had full access to all of the data in printing of parts required for the assembly the study and takes responsibility for the integrity of the of ICU ventilators. It was involved in the aero-­MEDEVAC and the EMRSSA field data and the accuracy of the data analysis. All authors development and the equipping of the hospital in Mulhouse. contributed equally to the study concept and design, EMRSSA field hospital. As such, in less acquisition, analysis or interpretation of data literature than a week, the EMRSSA field hospital search, drafting of the manuscript, critical revision of ​ENGAGEMENT OF FRENCH MILITARY the manuscript for important intellectual content, and was fully equipped with ICU capacities and MEDICAL ACADEMY STUDENTS administrative, technical or material support. used three large-capacity­ oxygen concen- The students of the French Military Funding The authors have not declared a specific trators (Module de Production d'Oxygène Medical Academy have taken part in the grant for this research from any funding agency in the Grande Capacité, high-­capacity oxygen fight against the COVID-19 pandemic. public, commercial or not-­for-­profit sectors. generator module) producing oxygen at All of the academy students volunteered. Disclaimer The views expressed in this manuscript 250 L/min. The French military medical Cadets in their second to sixth year of are those of the authors and do not reflect the official supply chain equipped medical treatment policy of the French Military Medical Service. medical or pharmacy studies and second-­ facilities for overseas military operations year and third-­year nursing students were Competing interests None declared. with increased capabilities of two-­bed involved. This deployment across the Patient consent for publication Not required. intensive care modules and supporting the national territory was their very first mili- Provenance and peer review Not commissioned; expansion of SARS-­CoV-2 tests. tary operation. Before deployment, they externally peer reviewed. received information about COVID-19 This article is made freely available for use in accordance with BMJ’s website terms and conditions ARMED FORCES BIOMEDICAL and appropriate training on how to use the personal protective equipment and how for the duration of the covid-19 pandemic or until RESEARCH INSTITUTE ACTIONS IN otherwise determined by BMJ. You may use, download THE FIGHT AGAINST THE COVID-19 to provide medical care while wearing it. and print the article for any lawful, non-­commercial PANDEMIC Depending on their level of study, they purpose (including text and data mining) provided that were employed as stretcher bearers, prac- all copyright notices and trade marks are retained. As early as January 2020, the Armed tical nurses, nurses, medicine or pharmacy copyright. Forces Biomedical Research Institute was © Author(s) (or their employer(s)) 2020. No commercial students, most of the time in emergency re-­use. See rights and permissions. Published by BMJ. working to combat the COVID-19 crisis departments or ICUs in the French mili- through scientific literature analysis and tary training hospitals and in the EMRSSA. medical evaluation and consultation Since 24 March 2020, 266 students have for authorities, especially when French To cite Pasquier P, Luft A, Gillard J, et al. been sent to reinforce the military medical nationals were evacuated from China. BMJ Mil Health Epub ahead of print: [please include treatment facilities, representing 30% of When the pandemic severely hit France, Day Month Year]. doi:10.1136/

the students of the military academy (42% bmjmilitary-2020-001569 http://militaryhealth.bmj.com/ the Armed Forces Biomedical Research of students beyond second grade) as of Institute activities were all redirected Received 20 June 2020 15 April 2020. Since then, there has been Revised 6 July 2020 towards helping all the FMMS units to a succession of replacements and rein- Accepted 6 July 2020 cope with the virus. The research response forcements. This constant adaptation to BMJ Mil Health 2020;0:1–6. was threefold: (1) set up a larger-scale­ the changing pressure of the COVID-19 doi:10.1136/bmjmilitary-2020-001569 RT-PCR­ diagnostic capability; (2) design pandemic on the healthcare system is the and conduct several research projects; and only way to ensure the sustainability of REFERENCES (3) help medical care providers by dissem- such reinforcements of caregivers. 1 Ministère des Armées. Mission of the military health inating a literature analysis. Since 11 service. Available: https://www.defense.​ ​gouv.fr/​ ​ March 2020, the Armed Forces Biomedical english/sante/​ ​introduction/mission-​ ​of-the-​ ​military-​ health-service/​ ​mission-of-​ ​the-military-​ ​health-service​ Research Institute helped set up the mili- CONCLUSION on September 24, 2021 by guest. Protected [Accessed 26 Apr 2020]. tary training hospital diagnostic RT-PCR­ In an unprecedented medical crisis, the 2 Pasquier P, Dubost C, Boutonnet M, et al. capabilities. It also increased its produc- FMMS engaged multiple actions, which Predeployment training for forward medicalisation in a tivity to 800 analysis a day. The Armed are still ongoing, in the fight against combat zone: the specific policy of the French military Forces Biomedical Research Institute also COVID-19 in France. Within a global health service. Injury 2014;45:1307–11. 3 Swiech A, de Rocquigny G, Martinez T, et al. Terrorist developed research projects in virology. medical system, innovative, dedicated threat: creating a nationwide damage control training It was involved in more than 20 research interventions brought together adaptive program for non-­trauma care providers. Anaesth Crit projects directly linked to the pandemic. solutions to issues encountered in the Care Pain Med 2020;39:59–64. It helped to select grant proposals for the COVID-19 pandemic. Finally, previously 4 Calamai F, Derkenne C, Jost D, et al. The chemical, Defence Innovation Agency. Finally, a task highlighted in the National Trauma Care biological, radiological and nuclear (CBRN) chain of survival: a new pragmatic and didactic tool used by force was set up to more fully engage the System, military and civilian trauma care Paris fire Brigade. Crit Care 2019;23:66. Armed Forces Biomedical Research Insti- systems were integrated to achieve ‘zero 5 Leone M, Bernard L, Brouqui P. Ebola virus outbreak: tute’s workforce and to deliver literature preventable deaths after injury’.35 The tribute to the French army health services. Anaesth Crit analysis to medical care providers and collaboration between civilian and mili- Care Pain Med 2015;34:307–8. 6 Pohl J-­B, Mayet A, Bédubourg G, et al. The 2009 professional associations. More than 20 tary healthcare systems reinforced their A(H1N1) influenza pandemic in the French Armed reports have been submitted. Teams of shared objective: ‘saving the greatest Forces: epidemiological surveillance and operational the Armed Forces Biomedical Research number of lives’. management. Mil Med 2014;179:183–9.

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