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INTERNATIONALINTERNATIONAL REVIEWREVIEW OFOF THETHE ARMEDARMED FORCES FORCES MEDICALMEDICAL SERVICESSERVICES

REVUE INTERNATIONALE DES SERVICES DE SANTÉ DES FORCES ARMÉES

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

Quarterly : September 2010 • Trimestriel : septembre 2010 VOL. 83/3 Working Closely for Five Decades

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Copyright © 2010 Meridian Medical Technologies®, Inc., a wholly owned subsidiary of King Pharmaceuticals®, Inc. All rights reserved. MMT6779 01/2010 International Review of the ARMED FORCES MEDICAL SERVICES

Revue Internationale des Services de Santé des Forces Armées

Official organ of the International Committee of Military Medicine

Organe officiel du Comité International de Médecine Militaire

VOL. 8283/1/3 SCIENTIFIC COMMITEE / COMITÉ SCIENTIFIQUE EDITION / REDACTION

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org (Germany / Allemagne) . Assistant Chief-Editor / Rédacteur en chef adjoint Col. (Dent.) JJ BRAU Maj. Gen. (MD, Prof.) M. MORILLON (France / France) [email protected]

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

39 Medical Planning of Chinese Armed Forces in ORIGINAL ARTICLES / ARTICLES ORIGINAUX 5·12 Wenchuan Earthquake Rescuing Operations. By S. GUO, Z. YANG, X. WU, C. CHEN, Y. LI and L. MA. P. R. of China. 5 EDITORIAL By Colonel M. LEMMENS, MD 44 Deputy Secretary-General of the ICMM. Health Risks Assessment in Operations. A French Focus. By V. DENUX and N. GRANGER-VEYRON. France. 6 Medical Aspects in Military Missions in IRAQ By K. KANEV, S. TONEV, E. BELOKONSKI and K. KATZAROV. 48 Bulgaria. Monitoring Performance Changes with On-Board Data Recording System. By A. GRÓSZ, J. HORNYIK, E. TÓTH and A. SZATMÁRI. 12 Hungary. Safety of Altitude Chamber Training Operations in the Italian Air Force Experience. By F. MORGAGNI, A. AUTORE, A. LANDOLFI and 55 G. CINIGLIO APPIANI. Italy. Piqûres de scorpion : Attitude des Services de santé militaire Algériens. Par D. BACHA. Algérie. 19 An Unusual Case of Firearm Injury to the Face with Bullet Cover Lodged in the Nose. 60 The War Veterans’ Silent Killers. By S. AL SAIF and K. AL-SHAIKH. By E. GERDING. Argentina. Kingdom of Saudi Arabia.

24 Safe Deployment of Soldiers with Type 1 Diabetes Mellitus. INFORMATIONS ON ICMM By Y. S. CHOI and J. C. NANCE. U.S.A. INFORMATIONS DU CIMM

31 Modern Medical Stability Operations: Advancing 38 39 the Standards of Care. Add-in folder between the pages By W. ANDERSON, P. LARABY, G. NAKANO, M. MAHMOOD 38 39 and D. NOAH. U.S.A. Encarté entre les pages

Photo on the cover: Exercise during a course of medical support in the Kingdom of Saudi Arabia.

Views and opinions expressed in this Review are those of the authors Les idées et opinions exprimées dans cette Revue sont celles des auteurs et VOL. and imply no relationship to author’s official authorities policy, present ne reflètent pas nécessairement la politique officielle, présente ou future 83/3 or future. des autorités dont relèvent les auteurs.

International Review of the Armed Forces Medical Services 4 Revue Internationale des Services de Santé des Forces Armées EDITORIAL EDITO EDITO

2010 is the year of the regional congresses, and for the first time in its history, ICMM holds six regional congresses within a few months. This is a response to the will of the General Assembly of the Heads of delegations to stay in close contact with all the parts of the World and to their demand to organize courses and scientific activities on regional base. The first ICMM Pan European Congress in Svetlogorsk (Kaliningrad, Russia) from 7 to 11 June 2010 was the first ICMM Regional Congress this year. The ICMM Pan European Regional Working Group (RWG) was created by France, Netherlands, Russia, Serbia and Switzerland, and no doubt they will be joined by many other European countries in the future. As each ICMM RWG will do this year, the Regional Assembly of the Pan European RWG made remarks on the draft strategic plan to be presented next year during the General Assembly of the World Congress in Nigeria. Such an exercise is very important. A growing organization as ICMM needs to assess its objectives and its means for the future. We wish a big success to the organizers of the next ICMM regional congresses and we hope that many officers of the health services will participate to the ICMM regional congress of their region, in order to exchange experiences of scientific value and why not, to make scientific presentations: this allows them to propose an article to be published in our international review. All the activities of ICMM are presented in our review, and can also be found on the website of ICMM: www.cimm-icmm.org. You can find there the last information about the timing and organization, and links for subscription. Col. LEMMENS Marc, MD Deputy Secretary-General

2010 est l’année des congrès régionaux, et pour la première fois dans son histoire, le CIMM va tenir six congrès régionaux en quelques mois. C’est la réponse à la volonté de l’Assemblée Générale des Chefs de délégations de rester en contact étroit avec toutes les parties du monde et à leur demande d’organiser des cours et des activités scientifiques sur une base régionale. Le premier Congrès Pan Européen du CIMM à Svetlogorsk (Kaliningrad, Russie) du 07 au 11 juin 2010 était le premier Congrès Régional du CIMM cette année. Le Groupe de Travail Régional (GTR) Pan Européen du CIMM a été créé par la France, les Pays-Bas, la Russie, la Serbie et la Suisse, et il n’y a pas de doute qu’ils seront rejoints par beaucoup d’autres pays européens dans le futur. Comme chaque GTR du CIMM le fera cette année, l’Assemblée Régionale du GTR Pan Européen a commenté le projet du plan stratégique qui sera présenté l’an prochain pendant l’Assemblée Générale du Congrès Mondial au Nigéria. Un tel exercice est très important. Une organisation en pleine croissance comme le CIMM doit fixer ses objectifs et ses moyens pour le futur. Nous souhaitons plein succès aux organisateurs des prochains congrès régionaux et nous espérons que beaucoup d’officiers des services de santé participeront au congrès régional de leur région, de façon à échanger des expériences sur base scientifique et pourquoi pas, faire des présentations scientifiques : cela leur permettra de proposer un article pour une édition dans notre revue internationale. Toutes les activités du CIMM sont présentées dans notre revue, et peuvent aussi être retrouvées sur le site Internet du CIMM : www.cimm-icmm.org. Vous y trouverez les dernières informations concernant les horaires et l’organisation, et des liens pour les inscriptions. Médecin Colonel LEMMENS Marc Secrétaire Général Adjoint VOL. 83/3

International Review of the Armed Forces Medical Services 5 Revue Internationale des Services de Santé des Forces Armées Medical Aspects in Military Missions in IRAQ.* ARTICLES ARTICLES ARTICLES ARTICLES

By K. KANEV❶, S. TONEV❷, E. BELOKONSKI❸ and K. KATZAROV❸. Bulgaria

Kamen Petrov KANEV

JOB POSITION: Military doctor in regiment, Radomir, Bulgaria (1980-1981). Post-graduate student in Medical Defense, Military Toxicology, Radiology in Higher Military Medical Institute, PhD (1981-1985). Deputy-head of Department of Medical Control at Ministry of Defense (1986). Head of Department of Medical Control at Ministry of Defense (1988). Assoc. Prof. in Toxicology (1990). Head of I Dept. of Internal Diseases (1992). Deputy-director of Governmental Hospital «Lozenec» (1994–1999). Head of Department of Public Health at District Health Center, Sofia (2002). Assoc. Prof, in the Faculty of Emergency and Intensive Medicine, Military Medical Academy, Sofia (2003) & continues. Chief of Clinic «Toxicology and allergology» (2007) and continues. Chief of Chair of «Disaster Medicine and Toxicology» (2004) & continues. Secretary of the Specialized Scientific Council of Military Medicine in Bulgaria. Secretary of the scientific journal «Military Medicine». Vice president of National Bulgarian Association for Reserved Officers.

RÉSUMÉ Aspects médicaux dans les missions militaires en Irak. Le soutien médical aux opérations de maintien de la paix a le devoir de fournir des soins adaptés aux forces engagées. Des mesures préventives s’avèrent nécessaires pour réduire le risque médical. L’objectif de cet article est de présenter une analyse du système de santé du pays hôte dans le secteur de responsabilité médicale du contingent Bulgare déployé en Irak. Cet article décrit les principaux risques sanitaires menaçant les militaires déployés en Irak. La description du système de santé du pays est analysée et des recommandations sont faites pour le personnel soignant en mission. Il apparaît que le système de santé de l’Irak ne correspond pas aux normes Européennes ou Nord-Américaines et qu’on ne peut pas faire à lui lors des missions militaires.

KEYWORDS : Medical aspects, Military missions, Risk factors, Healthcare. MOTS-CLÉS : Aspects médicaux, Opérations militaires, Facteurs de risque, Soins.

INTRODUCTION every day the Iraqi civilians are dying as well as governmental security, local and foreign military personnel. Since the beginning of the military intervention of the The coalition deaths are presented in Table 1. USA (March 2003) Iraq has been in a flood of violence and chaos. At the end of the military actions (01 ❶ May 2003) neither of the Iraqi government, nor the new Assoc. prof., MD PhD DSc. constitution managed to make the people trust them, ❷ Major Gen., MD PhD. nor to guarantee the security and order in the country, ❸ Colonel, MD PhD. nevertheless they received support from the coalition Correspondance: forces and the international community. The situation in Col.(r), Assoc.Prof. Kamen Petrov KANEV, MD, PhD, DSc Military Medical Academy the country was described by all observers as extremely Chair Disaster Medicine and Toxicology, Clinic of Toxicology hard and getting worse. 3, “St. Georgy Sofiisky” str., 1606, Sofia, Bulgaria VOL. * Presented at the 38th World Congress on Military Medicine, 83/3 Although at present the hostility is much lower, nearly Kuala Lumpur, Malaysia, 4-9 October 2009.

International Review of the Armed Forces Medical Services 6 Revue Internationale des Services de Santé des Forces Armées Table 1. THE INFECTIOUS DISEASES ARE A MAJOR RISK Australia 2 Latvia 3 Without taking precautions the effectiveness of the Azerbaijan 1 Netherlands 2 military contingent can be severely reduced. The main risk diseases while performing military operations in Bulgaria 13 Poland 22 Iraq are also these typical for the country: Czech Republic 1 Romania 3 Gastroenterological diseases: Diarrhea syndrome, dys- Denmark 7 Slovakia 4 entery, Hepatitis A, abdominal typhus, paratyphoid, etc. Transmissive diseases: Malaria in certain endemic cen- El Salvador 5 South Korea 1 ters, Leishmaniasis, Crimean-congo hemorrhagic fever, Estonia 2 Spain 11 typhoid. Anthropozoonosis: Rabies. Fiji 1 Thailand 2 Sexually transmitted diseases: Hepatitis B, AIDS, Georgia 5 Ukraine 18 gonorrhea. Hungary 1 United Kingdom 176 Skin and tissue diseases: leptspirosis, schistosomiasis Air-drop infections: Tuberculosis. Italy 33 United States 4195 Kazakhstan 1 Leishmaniasis, malaria, and drug-resistant bacterial Total 4509 infections (specifically, infection with Acinetobacter baumannii) are among the entities most likely to be seen in personnel who have returned home after sup- COALITION DEATHS IN IRAQ BY porting Operation Iraqi Freedom and who present with NOVEMBER 13TH, 2008 diseases that have prolonged incubation periods or require prolonged therapy. Some of the possible reasons leading to the remaining strain in the country are the following: Stress and combat stress is evaluated by the following 1. The presence and the actions of the coalition risk factors: forces. 1. Daily encounter with asymmetric combat actions 2. The inability of the authorities to protect the and the consequences resulting from them. population and safeguard the life of the citizens. 2. Monotony. 3. Feuding between the sects of the different reli- 3. Alienation. gious communities. 4. The clash of cultural and moral values. 4. The inability of the authorities to guarantee the 5. The long-term separation from family and loved- survival needs of a large part of the population (home, ones, as well as from the usual working environment. food, water, medical services, electricity, work). 6. Surrounding environment, acting as a life and 5. Widespread impoverishment of the population. health threat, as well as limited and modulator of behavior. The presence of the coalition forces in Iraq as well as 7. The information about the large number of disa- their combat operations (including the deployment of bled veterans from the global war against terrorism - heavy military equipment and aviation) aiming at according to data of the Center for Military Veteran freeing certain regions from rebels, lead to wiping the Aid, 152 669 former servicemen submitted applications extremist groups out, but at the same time cause the for granting benefits for different degree of disability death of many innocent civilians including women and until 20 July 2007. children and provoke anger and straightforward resistance among part of the population. This resistance is The major stress factors during a mission in Iraq are the expressed through constant terrorist acts directed asymmetric war actions peculiar for the modern type of mainly against the American army, but also against the war, especially the war against the international terro- coalition forces1. rism. The insecurity arising from the nature of the combat actions under conditions of absence of enemy’s for- RISK FACTORS mations and a war line, the fact that an attack may be launched at any time by everybody and everywhere are The medical threat to military personnel is tightly all factors that would be an ordeal to every type of ner- connected with the risk factors which are typical for the vous system. The stress due to the constant risk of country. The high risk factors are related to: facing an attack is multiplied by the monotony of the 1. Disease, everyday life in the camp and the forced alienation of 2. Combat stress, the personnel from the local citizens. The clash of value 3. Improvised explosive devices and bomb assaults, systems of participants in the mission and locals as a suicide bombers, ambush using conventional or hand- result of different manners and customs, religious and made weapons, philosophical beliefs add up to the bad microclimate 4. Mines and unexploded ordonance, within the contingent. The necessity to perform tasks in 5. Toxic industrial substance usage for terrorist aims a an unfamiliar and often hostile environment also VOL. and the moderate to low risk factors are those concer- contribute to the escalation of the nervous tension of 83/3 ning NBC usage by terrorists. the personnel.

International Review of the Armed Forces Medical Services 7 Revue Internationale des Services de Santé des Forces Armées Terrorism Iraqi guerilla attacks against Multi-National Force - Iraq, Iraqi government and other targets typically take the following forms: • Attacks on convoys and patrols using road mines and improvised explosive devices. • Ambushes on Coalition forces with small arms and/or rocket propelled grenade fire and hit-and-run mortar strikes on Iraqi government, Iraqi security forces, and MNF-I bases are also common. • Sabotage of oil pipelines and other infrastructure is another tactic often used. quantities of antrax, ricin and botuline toxin were pro- • Assassination of Iraqis cooperating with the duced. Despite the declared CWA production facilities Coalition forces and Iraqi government. and the destroyed supplies of these substances, it is • Suicide bombings targeting international organi- presumed that there are other supplies in the country zations, Coalition forces, Iraqi police, hotels, etc. which have not been declared and that it is possible • Kidnapping and murder of private contractors such substances to be produced at a smaller scale. From working in Iraq for Iraqi government, MNF-I, or for historical point of view in 1984 Iraq became the first commercial entities. nation to use a nerve agent on the battlefield when it • Kidnapping private Iraqi citizens as a fundraising deployed Tabun-filled aerial bombs during the Iran-Iraq tactic. war- 5500 Iranians were killed by the nerve agent bet- • Murder of medical specialists. ween March 1984 and March 1985. Some 16000 Iranians were reported killed by the toxic blister agent mustard Mines gas between August 1983 and February 19865, 6. These Many mine fields and unexploded munitions have facts may serve as an indicator for future awareness of remained from the wars and the internal conflicts in possible chemical agent usage as a terrorist weapon. Iraq. Their exact number and location, with a few exceptions, is unknown. Their distribution (thousands ORGANIZATION AND POTENTIAL OF of mine fields) is mainly in the northern regions (with HEALTHCARE SYSTEM IN IRAQ concentrated Kurds and on the border with Turkey), along the Iran – Iraq border, the central and southern Medical aid and the organization of the healthcare in Iraq parts of the country and especially in the regions do not meet the European and American standards. The Sulaymaniah, Penjwin, Sharbazher Qaladiza. hospitals and the emergency units and the units for urgent medical aid cannot be used to provide for the medical support of the personnel. The distribution of the medical establishments in the country is absolutely ineffective – the Ministry of Healthcare reports that in the provinces Misan, Wasit, Nasiriya and Bas the healthcare centers in more than 37 regions either do not function, or there are not such (the population is more than 150 000). Healthcare in Iraq is governed by the Ministry of Healthcare of Iraq and is aided by the Coalition Provisional Authority. Medical services in the country are mainly delivered by the medical establishments of the Ministry of Healthcare and to a lesser degree by private medical establishments. The existing units for emergency and urgent aid are insufficiently equipped and are located mainly in the big urban centres, and what is more, their efficiency is good only in some of the regions of the capital. The condition of the operating rooms in many of the hospitals is below any standards Toxic Industrial Substances while the hospitals are trying to function with the availa- In three bomb attacks with chlorine gas in Baghdad ble means. The Iraq Medical Association reports that and in Anbar province killed 41 people and wounded 90 percent of the almost 180 hospitals in Iraq lack essential 181 which led to traumatic and intoxication injuries. equipment. There are no supplies of medicines even in the emergency and urgent aid centre in one of the busiest BOMB TRUCK WITH CHLORINE GAS hospitals in Bagdhad "Yarmouk", Five people die on average every day because medics and nurses don't have the NBC equipment to treat common ills and accidents. That trans- The potential risk of exposure to ionizing radiation is lates to more than 1,800 preventable deaths in a year in related mainly to the terrorist acts, in which “dirty that hospital alone. bombs” are used. Most probably the biological agents VOL. produced before the Persian Gulf War are inactive but According to data of the Ministry of Healthcare of 900 83/3 there is presumption that between 1998-2002 small basic medicines only 401 were available in the stores of

International Review of the Armed Forces Medical Service 8 Revue Internationale des Services de Santé des Forces Armées the hospitals, anesthetics antibiotics, drug preparations contingent), hepatitis A – could affect 1% to 10% of and medicines for treatment of malignant diseases are personnel that has consumed local water and food, available in critically small quantities and in some periods Crimean-Congo hemorrhagic fever, West-Nile Fever, of the year they are lacking. The lack of volume-replace- typhoid, Papatasii fever (Sand Fly Fever). ment liquids, oxygen, catheters is typical even for the big 2. Transmissive diseases: Increasing morbidity rate healthcare establishments. About 90 children died in among the local population from leishmaniasis – muco- Basra as result of the lack of medicine, a worse figure than cutaneous and visceral forms, low to moderate opera- for the same period last year, when some 40 children died tional risk of malaria. for similar reasons. 3. Bombing and suicide assaults, ambush using conventional or improvised weapons. The supplies of disinfectants, bandages, linen and food 4. The health care system cannot be used for the mis- are as insufficient as the supplies of medicines. Despite the sion medical care because: international assistance and the aid received from the a. The qualification of the medical specialists and USA, the condition of the Iraqi healthcare system may the healthcares does not meet the standards of NATO. well be compared to a freely falling body – the worsening b. The conditions in the health institutions – of the quality and quantity of the offered medical services hygiene, location, medical equipment, maintenance of is a tendency which is maintained by the insecurity in the the equipment, despite the reconstruction of a large country. Thousands of American and Iraqi casualties have part of them with foreign assistance are far below the been treated at the American military hospital in Balad NATO criteria for a health institution. (about 68 km north of Baghdad), Iraq. Many of the recent c. Blood and blood products supplied by the casualties were Iraqi police and soldiers. But the hospital international governmental and non-governmental also treats civilians and even insurgents, offering the same organizations can be considered to be safe to use while care that an American soldier would receive. those supplied from Iraq are not. d. There are no supplies of medicines and vaccines The number of the medical specialists is absolutely insuffi- for the medical centers, and most of them are not pro- cient and continues to decrease because of the insecurity vided with life-preserving medicines, even syringes and in the country and the terrorist acts directed to the health- bandages. care centers and the medical specialists. According to the f. The military medical services are incorporated data from the Ministry of Healthcare and the International in the civil ones. Part of the servicemen having become red half-moon since the onset of the military actions of the victims of the terrorist war are treated in the military coalition forces in 2003 more than 2000 doctors have been field hospitals of the coalition forces. killed only in Bagdhad so far, not much different are the g. The organization of emergency and urgent data from Mosul. Often, the doctors and the nurses are medical aid is inefficient because of the insufficient cove- kidnapped for ransom. Another threat to the medical staff rage of the country, lack of medical specialists, lack of is the frequent interference/intrusion of armed groups in medical equipment and means for financing its activities. their activities – the medical specialists are forced to treat In the suburbs ad the rural regions, a network of units for patients from the armed group under menace of arm lea- emergency medical services practically does not exist. The ving other patients with life-threatening conditions. Very ambulances and the motor vehicles labeled for transpor- often the real estates and the families of the medical spe- tation of wounded are often attacked by terrorists or cialists are subject to terrorist acts as a response to their detained for checking at the traffic checkpoints. participation in saving the life and health of members if the opponents religious or clan group. There are daily RECOMMENDATIONS situations of armed groups taking the law in their hands to kill and not let patients in the medical centers. I. Personnel Healthcare

In a meeting in Washington Iraqi Surgeon General Brig. Protecting the personnel against diseases and injuries Gen. Samir A. Hassan said that the Iraq’s military medical which do not result from military operations is of great system is not equal to its U.S. counterpart, but is improving importance in order to maintain the readiness of the on a daily basis. Iraq’s military has good Level II medical troops to carry out tactical and operational assignments. centres, which provide basic emergency care. But the mili- Commanding officers on all levels are responsible for tary depends on the country’s civilian Ministry of Health the implementation of effective measures assuring the for sophisticated Level I trauma care, like major surgery. An protection of the personnel's health. Medical officers area that needs to be improved among his medical corps have an obligation to identify health threats and is its response time to wounded troops. About 40% of recommend adequate counter-measures. Special atten- Iraq’s wounded troops die compared to 95% survival of tion is given to infectious diseases. Although these the American troops. recommendations are mainly intended for military field operations, they can easily be adapted to the needs of CONCLUSIONS civilian contingents travelling and/or working in Iraq. The health threat to the personnel dislocated on a mis- 1. Recommended measures for preserving the health sion in Republic of Iraq is estimated to be high because of the personnel during a mission (on location) of the following risk factors: 1. To have on location the necessary medical staff VOL. 1. Diseases with high and moderate operative risk- for prevention and treatment of diseases and trauma 83/3 diarrhea-bacterial (to 100% morbidity among the along with all medical equipment needed.

International Review of the Armed Forces Medical Service 9 Revue Internationale des Services de Santé des Forces Armées 2. To provide the necessary and sufficient safe drin- 3. Strict adherence to the rules regarding the use of king water, ice and food. personal protection means. 3. The provision of food and water supplies should 4. Strict adherence to instructions regarding only be provided by periodically controlled suppliers actions and measures for the reduction of the harmful operating at European and American standards. effects of the environment. 4. Preparation and processing of food products as 5. For personal safety it is necessary that personnel well as the preparation of food should be in accor- should be provided with individual dosimeters. In the dance with the respective normative requirements. event of being exposed to doses of around 6 mSv it is 5. Not to consume food, water or ice from local necessary to report this up the command chain. retailers under any circumstances. 6. To ensure the hygiene, disinfection, and confir- 3. Medical support mation of the location. Because of the low level health care in Iraq the medical 7. To construct field toilets in accordance with nor- support of the peace keeping troops has to follow the mative regulations. four NATO level echelon concepts. It is necessary to 8. To provide the necessary products for washing plan and practise an independent medical support in hands – water and soaps – near toilets and feeding an unreliable environment, in a way which will not dif- places and to enforce washing of hands. fer from military troops native countries, in the good 9. To ensure the collection, depositing and disposal medical practice manner. of waste in accordance with normative regulations. 10. To remove all possible sources of food waste, SUMMARY which could attract animals and insects from the area of deployment. The medical support in peace keeping operations has 11. To enforce the proper use of chemical preventa- the obligation to provide adequate medical care for tive treatment against malaria, in accordance with the the participating military forces. Preventive medical medical service’s prescribed schedule. measures are necessary in order to reduce the medical 12. To enforce the use of means for personal protec- risk. The aim of the article is to present the required tion. analyses concerning host nation healthcare system in 13. To see to and require the proper wearing of uni- the military medical assessment of deployed Bulgarian forms (impregnated with permethrin) – long sleeves contingent area of responsibility in Afghanistan. The and proper tying of shoe laces, in accordance with cli- article reveals the main health risk factors to the matic conditions and tactical situation. deployed military personnel in Iraq. The organization 14. To enforce the use of DEET during the night and of the healthcare system in the country is outlined and day in accordance with the instructions of the medical recommendations for the personnel healthcare during service. mission are described. In conclusion it is stated that the 15. To sleep under a mosquito protection net health care system in Iraq does not meet the European (impregnated with permethrin). and USA standards and is not suitable for the medical 16. To promote the avoidance of sexual intercourse needs of the military missions. and encourage the use of condoms during sexual interactions. REFERENCES 17. To survey all vectors and control their number 1. KANEV K, E. BELOKONSKI, K KATSAROV et col. Medical should they exist. support principles and current Military Missions medical 18. To evaluate the potential risk the surroundings Assessment, Editor Maj. General Stoian Tonev, Publ. pose if necessary. House Irita, Sofia, 2008. 19. To observe climatic conditions and enforce the respective work/rest scheme in accordance with tempe- 2. FOSSE Erik, Establishment of a NATO trauma registry- a rature conditions. joint project within the NATO framework, Medical Corps, 1, 2009. 20. To observe the sick rate and traumatism not resulting from field operations and the respective data 3. CLINTON M. A, KURRAY K.: Infectious disease challenges should be forwarded up the command chain in accor- in military personnel returning from Iraq and dance with normative documents. Afghanistan, Infections in medicine 2006, vol. 23, no. 1. 21. To conduct a survey if the sick rate is higher than the expected and to implement the necessary measures 4. Operation Iraqi Freedom, Official website of Multinational Force- Iraq, Terrorist tactics, May 2009, for reducing the sick rates. www.mnf-iraq.com.

Before leaving the field operations area, an evalua- 5. Key Findings of the Comprehensive Report of the Special tion of the health state of the personnel should be Advisor to the DCI on Iraq’s WMD, September 30, 2004- conducted. www.fas.org.

2. Traumas Prevention 6. Chemical Weapons Programs: History- www.fas.org. 1. Strict adherence to safety instructions regarding 7. Steven Donald SMITH, American Forces Press Service, technical equipment, transport and convoys. VOL. US Department of Defence, Iraq’s Military Medical 83/3 2. Strict adherence to instructions about operations Capability Improving, Iraqi General Says, Aug 2006- outside base camp. www.defenselink.mil.

International Review of the Armed Forces Medical Service 10 Revue Internationale des Services de Santé des Forces Armées The EZ-IO is the recognized technology standard for intraosseous access, and is deployed by military services worldwide. For more information, visit Vidacare.com.

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Image courtesy of US Army, Tech. Sgt. Jeremy T. Lock Safety of Altitude Chamber Training Operations in the Italian Air Force Experience.* ARTICLES ARTICLES ARTICLES ARTICLES

By F. MORGAGNI, A. AUTORE, A. LANDOLFI and G. CINIGLIO APPIANI. Italy

Fabio MORGAGNI

Lieutenant Colonel Fabio Morgagni is Chief of 1st Group High Altitude and Extreme Environments, Aerospace Medicine Department, Italian Air Force Flight Test Center. After graduation in Medicina et Chirurgia from the University of Florence and from the ITAF Medical Academy in 1988, he was graduated as specialist in Pneumonology (1994) and Cardiology (1999) from the University of Milan. Then he was also graduated from the Italian Air Force Air War College (2005) and from the Italian Joint Services Staff College (2007). Dr. Morgagni serviced as Head of Medical Unit, 53rd Fighter Wing – Cameri, Chief of Cardiology Department, ITAF Infirmary – Milan, Chief of Pneumonology and Respiratory Physiology, ITAF Aeromedical Institute – Milan, and Chief of Cardiology 1, ITAF Aeromedical Institute – Milan. He completed several duty periods in Balkans and Iraq. His principal interests are on breathing strategy, ventilatory response to hypoxia and exercise, and cardiac and respiratory adaptations to extreme environments such as high altitude and spaceflight. In these fields, he is author or co-author of several papers. Dr. Morgagni is qualified as BLS-D executor, PHTLS executor, MIMMS executor and instructor. Born in Rome, he is married to the former Loredana La Penna and they have three children.

RÉSUMÉ Expérience de l’Armée de l’air Italienne en matière de sécurité de l’entraînement en caisson de décompression. Le caisson de décompression est le nec plus ultra en matière d’entraînement en hypoxie et hypobarisme, bien que plusieurs incidents aient été rapportés, comprenant des barotraumatismes et des troubles de décompression. Pour réduire les effets adverses du séjour en caisson, nous avons changé les protocoles habituels afin de limiter le temps passé en altitude et de contrôler les participants avant la session. Nous avons évalué la sécurité des caissons de décompression en étudiant les résultats observés chez 1.245 personnels navigants et parachutistes militaires qui ont suivi cet entraînement de 2003 à 2009. Nous avons dénombré 32 cas d’effets adverses, soit une prévalence de 2,6%. On a observé un cas de troubles de décompression, soit 0,08%. Les barotraumatismes, affectant principalement l’oreille moyenne, représentaient 9 cas, soit 1,5%. Nous avons également trouvé quatre cas de syncope (prévalence 0,3%). Du fait que l’effectif de notre population est limité et que les résultats ne peuvent être comparés à ceux d’autres études, nos données appellent d’autres investigations.

KEYWORDS : Hypobaric chamber, High altitude training, Decompression sickness. MOTS-CLÉS : Caisson de décompression, Entraînement en haute altitude, Troubles de la décompression.

INTRODUCTION The major concern is about the decompression sickness (DCS)2, for which studies reported a mean prevalence Altitude chamber is the gold standard for aircrews training on hypoxic and hypobaric environment, and its Correspondance: implementation is mandatory in the Italian Air Force Lt Col Fabio MORGAGNI, MD, Italian Air Force – Flight Test Centre – Aerospace Medicine Department under operational guidelines that are coherent with “Mario de Bernardi” Airport NATO STANAG 3114 Ed. 1986. Since the low-pressure Via dell’Aeroporto di Pratica di Mare, 45 I-00040 Pomezia (RM) chambers became available in the aeromedical prac- Italy tice, all operators have reported several incidents, Email: [email protected] VOL. generating some criticism about the safety of these * Presented at the 38th World Congress on Military Medicine, 83/3 Kuala Lumpur, Malaysia, 4-9 October 2009. facilities and their real effectiveness as training tools1.

International Review of the Armed Forces Medical Services 12 Revue Internationale des Services de Santé des Forces Armées ranging between 0.01 and 0.25%,3 – 5 with a peak of of the oxygen supply. After completing the hypoxia 0.39%6. The prevalence is sensibly increasing, as indicated demonstration and descent to 18,000 feet, the lights by several investigators, and somewhat higher among were turned off for night vision demo. The individual the inside observers than in trainees3, 4. There is also evi- hypoxia time duration limits at 25,000 feet and at dence that the main presentation form of altitude indu- 18,000 feet were set at 4 minutes and at 15 minutes, ced DCS is the type I4, 6, with joint pain only, although stu- respectively. dies frequently reported the DCS type II5. A second group of incidents is represented by barotrauma7, 8, mainly invol- Type 2 profile. ving the middle ear. Barotrauma is frequently detected This was the standard profile for basic courses of stu- with variable incidence after hypobaric chamber ses- dent pilots. After sinus check and 30 minutes denitro- 9 sions , but it is also considered as a near normal physiolo- genation, the altitude of 35,000 feet was reached at gical reaction than an adverse effect, and its real preva- rate of 4,000 feet per minute for hypobarism and posi- lence is underestimated. Alternative training tools, like tive pressure breathing demonstration, while the trai- 10, 11 the reduced oxygen mixtures breathing (ROB) , were nees were requested to speak against the oxygen flow proposed to avoid the decompression sickness, although inside the mask. Without staying at 35,000 feet, the this could negatively affect the training on hypobarism. hypoxia and the night vision impairment demonstra- In order to investigate the safety of altitude chamber tions were conducted respectively at 25,000 feet and at training in Italian Air Force we reviewed the local data- 18,000 feet, as described above. base of hypobaric chamber sessions that took place in the ITAF Flight Test Centre, Aerospace Medicine Department, Type 2a profiles. which is the unique high altitude test facility in Italy. We This was a special profile for jet pilots assigned to high trained 1,254 Italian Air Force aircrews and Italian Army performance aircrafts. It was different from the type 2 paratroopers using profiles similar to those adopted by for the maximal altitude that was set at 43,000 feet. other military operators. In order to minimize the adverse effects of hypobarism the maximum altitude was limited, Type 3 profiles. and a special set of safety procedures were implemented including an accurate pre-flight medical check of the trai- It was a rapid decompression simulation with ascent nees, a continuous medical monitoring of all personnel from 8,000 feet to 22,000 feet in less than 3 seconds, inside the chamber, and a denitrogenation for 30 while the trainees had practice with sudden gas expan- minutes with 100% oxygen breathing. sion and fog. All personnel admitted to the chamber provided a valid certification by the ITAF aeromedical METHODS institute for flight duties or altitude exposure. The chamber protocol included: We reviewed the database of hypobaric training from a) pre-flight medical check with ear, nose, and throat January 2003 to April 2009. All cases with any disturbance examination and tympanometry; reported by the trainees or detected by the physician before, during, and after the chamber were extracted b) real time monitoring of blood saturations, ECG, and from the database and analyzed. The hypobaric chamber breathing; is a model developed by AMST Systemtechnik GmbH – Ranshofen (Austria) that was charged in 2003. The cham- c) preventive denitrogenation with 100% oxygen brea- ber is conducted according to the operational procedures thing for 30 minutes for all profiles. All trainees had to released by the factory and the safety requirements of stay in the facility for almost one hour after the cham- pressure driven systems stated by the European Union ber, and those suffering by any discomfort received a and Italian laws. A dedicated hyperbaric chamber is ready post-flight medical evaluation immediately and the day to operate on site for the treatment of DCS. The trai- after. A supervisor physician and a nurse specially training’s main objectives were the detection and recogni- ned for hypobaric chamber operations were always tion of hypoxia with emergency recover, and the impro- present on site, with a specialized hyperbaric physician vement of gas expansion countermeasures. Three of four and a nurse more who were present for profiles above profiles included hypoxia demonstration at 25,000 feet, 18,000 feet. Subjects affected by ear, nose, and throat and night vision impairment demo at 18,000 feet. One problems or any other disturbance incompatible with profile was the rapid decompression simulation. All our the altitude exposure were not cleared for the cham- profiles are briefly reported below. ber, and those who did not pass the sinus check were discharged. The diagnostic criteria for decompression Type 1 profile. sickness included the presence of joint pain, chokes, or This profile was designed for periodic courses and for marbled skin (DCS type I), and/or neurological impair- paratroopers training. After the sinus check at 5,000 ment (DCS type II) during or after the chamber. feet and 30 minutes of normobaric denitrogenation Barotrauma was defined according to the accepted with 100% oxygen breathing, the altitude of 25,000 standards including acute ear, facial or abdominal pain feet was reached at ascent rate of 4,000 feet per during ascent or descent. The middle ear barotrauma minute. At altitude, the trainees alternatively perfor- was defined as acute ear pain during altitude changes med a set of tasks until two or more symptoms of hypo- with or without retraction of the eardrum. The simple VOL. xia were detected, then they applied the emergency transient hearing loss without ear pain during altitude 83/3 recovery procedure that consists in the proper restore changes was considered a normal effect if it recovered

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Digital imaging made easy™ Manufactured by: SOREDEX Tel. +358 10 270 2000 [email protected] P.O.Box 148, FI-04301 TUUSULA, Finland Figure 1: Training profiles adopted by the Italian Air Force. The Type 2a is limited to 43,000 feet insteat 45,000 as stated by NATO STANAG 3114.

TYPE 1 TYPE 2 PERIODIC COURSE BASIC COURSE

Hypoxia demo PPB demo 30000 40000 Hypoxia demo 35000 25000 Night vision demo 30000 20000 Night vision demo 25000 15000 20000 15000 10000 Denitrogenation 10000 Denitrogenation 5000 5000 0 0 1 1121314151617181 11121314151617181

TYPE 2A TYPE 3 HIGH DYNAMICS RAPID DECOMPRESSION

50000 PPB demo 25000

40000 20000 Hypoxia demo 30000 15000 Night vision demo 20000 10000

10000 5000

0 0 1 1121314151617181 11121314151617181 !

spontaneously or with equilibrating maneuvers. Other DISCUSSION adverse effects were diagnosed according the generally accepted criteria. Data are presented as mean and rates are The major finding of our study is the relatively low pre- computed as proportion referred to one hundred persons. valence of altitude chamber related adverse effects. The decompression sickness accounted for 0.08%, less RESULTS than the mean reported prevalence, as indicated in Table IV. About Table IV, it must be clear that the sum- From January 2003 to April 2009, 171 hypobaric cham- marized data are purely indicative, because they were ber sessions took place at the Italian Air Force Test obtained with different chamber profiles, subjects, and Flight Centre, for a total of 1,254 simulated high altitude exposures (Table I). The most used profiles were Table 1: Training sessions performed from January 2003 Type 1 and 2, with only a small group of trainees under- to April 2009. gone the Type 3 with ceiling at 43,000 feet (Table II). YEAR CHAMBER EXPOSURES N. N. OF INSIDE Subjects that did not pass the medical check and were OF TRAINEES OBSERVERS initially not cleared for the session completed the trai- 2003 15 132 30 ning in a second time, once satisfactory recovered, and 2004 32 244 64 they were finally included in the analysis. 2005 29 201 58 2006 24 212 48 There were 32 cases of adverse effects with an overall 2007 27 168 56 prevalence of 2.6% (Table III). The decompression sick- 2008 34 202 68 ness accounted for one case only with onset at 40.000 2009 10 95 20 feet during the ascent to 43.000 feet. The presentation Total 171 1,254 344 form was Type I and it resolved during the emergency * Exposures for a group of 10 instructors. descent after the abort of the training. Due to the complete resolution once at ground, the patient received Table 2: Training courses from January 2003 to April 2009. normobaric 100% oxygen for two hours, instead of a YEAR CHAMBER EXPOSURES N. N. OF INSIDE run in the hyperbaric chamber, and he returned to his OF TRAINEES OBSERVERS duty without any limitation. The resulting prevalence Type 1 89 675 178 of DCS in our experience was 0.08%. Barotrauma was Type 2 77 560 154 diagnosed in 19 subjects, mainly as acute barotitis, with Type 2a 3 11 6 a prevalence of 1.5%. Among other incidents, we Other 2 8 6 VOL. found an interesting high occurrence of syncope, with Total 171 1,254 344 83/3 four cases and a prevalence of 0.3%. * Exposures for a group of 10 instructors.

International Review of the Armed Forces Medical Service 15 Revue Internationale des Services de Santé des Forces Armées Table 3: Hypobaric chamber adverse effects from Al-Wedyan and colleagues12 is based on a similar popu- January 2003 to April 2009. lation group of 705 subjects over an 8-year period. The ADVERSE CASES %INCIDENCE RATE* authors used different profiles with very high altitude EFFECTS OF EFFECTS % change rate of 11,000 feet per minute, and they repor- Ear barotrauma 19 59.4 1.5 ted a prevalence of ear and sinuses block of 5.0%. Decompression Those rapid altitude changes possibly had a role in the sickness 1 3.1 0.08 incidence of the reported adverse effects. The work of Syncope 4 12.5 0.32 Ohrui and coll.7 used profiles with altitude changes of Other 8 25.0 0.64 4,000 feet per minute. They found a prevalence of joint Total 32 100% 2.5% pain of 0.05%, similar to our 0.08%, and an ear/sinuses * Referred to 1,254 subjects. pain of 5.65%, greater than our but similar to that reported by Al-Wedyan. The wide variability of these methods. For example, the mean DCS prevalence of data about barotrauma suggests further investigations. 0.14% is biased by the work of Ohrui and coll., that did We improved the used protocols in order to minimize not report the case numbers, and by the work of Smart the risk of hypobarism related damage. First, the pre- and coll., that reported some unexplained cluster cases. chamber check at could appear excessive for personnel Excluding these works and considering only those just medically certified for flight duties. Moreover, the papers reporting data about the chamber¬related DCS, pre-flight tympanometry is not implemented elsew- the mean prevalence is 0.11%, that is inconclusive too, here. There is evidence that chronic sinusitis and mild because it does not necessary take count of the preven- forms of common cold could be present without any tive breathing of pure oxygen. The denitrogenation symptoms, and the possibility that subjects do not with 100% oxygen breathing has proven protective report the problem in order to complete the training 5 effects against the decompression sickness . We hypo- program without repercussions on his career is not to thesized to extend the denitrogenation period from 30 be excluded. Second, our profile 2a is actually limited to 45 minutes for Type 2a profile, based on the well to 43,000 feet, instead 45,000 feet adopted by other known inverse relation between time without nitrogen operators. The aim of this part is to improve the trai- 2 and probability of circulating bubbles . This relation, nee’s confidence with the positive pressure breathing that is not linear, was tested over long periods in the and its interference with radio communications. The case of extravehicular space activity and in the under- difference in terms of ambient pressure is limited, sea environment, but the real effectiveness of a 15 about 0.30 PSIA or 15 – 20 mmHg, absolutely not signi- minutes extent denitrogenation on high altitude DCS ficant as interference factor on the learning process was not investigated. The prevalence of barotrauma about hypobarism, while the risk of DCS could be was 1.5% in our subjects, less compared with other somewhat increased. We noted that all trainees were works. It is possible that the mild forms of barotrauma able to complete the PPB demo in 6 minutes during the were not properly reported by our trainees in order to ascent and descent phases between 31,000 and 43,000 avoid further examinations and waiver. We found four feet, and for this reason, the altitude was limited. The cases of syncope with a prevalence of 0.3%. The pre- real effect of this limitation on DCS risk is almost theo- sentation form varied from acute symptomatic brady- retical, because mathematical predictive models that cardia to loss of consciousness, and it was often observed are available for diving were not investigated in the after the oxygen restore following the hypoxia demo. high altitude environment. We did not perform any The reason for the immediate onset after oxygen restore cost-effectiveness analysis, because our data are is not clear, although it could be an hypoxia effect not actually poor. The Clinical examination made by a spe- immediately corrected by the oxygen. The major limit of cialist is probably expensive, but our department takes our study is the small population collected. The study of now benefit from the favorable contingency of a cer- Table 4: Hypobaric chamber related adverse effects. tain number of specialists that are simply available on site. In conclusion, we found that the altitude chamber AUTHORS EXPOSURES DCS NON-DCS is a safe and suitable environment to obtain a realistic Furry 1969 312,564 301 (0.10%) training until new more cost-effective tools become Bason 1976 88,520 79 (0.09%) available. The adverse effects as decompression sick- Furr 176 38,115 30 (0.08%) ness and barotrauma showed lesser incidence than that Bason 1982 57,400 87 (0.15%) published. For several reasons, including subject’s poor Piwinski 1986 14,545 20 (0.14%) co-operation, barotrauma is not adequately reported Bason 1991 136,696 140 (0.01%) as chamber related adverse effect. The future effort Al-Wedyan 1996 705 36 (5.5%) should try to correct this lack of information. We found Davenport 1997 5,885 (6.24%) also an unexpected incidence of syncope that will Ohrui 2002 58,454 (0.05%) constitute our investigation field in the immediate Rice 2003 38,153 94 (0.25%) future. DeGroot 2003 23,656 28 (0.11%) Smart 2004 10,851 42 (0.39%) 296 (1.25%) ABSTRACT Total 785,544 821 (0.14%)* 335 (0.04%)** * If considered 28 cases calculated from the study of Ohrui the total DCS cases are Altitude chamber is the gold standard for training on VOL. 849 for an overall incidence of 0.11%. 83/3 ** If considered 367 cases calculated from the study of Davenport the total Non- hypoxia and hypobarism, although several incidents have DCS cases are 699 with an incidence of 0.09%. been reported, including barotrauma and decompression

International Review of the Armed Forces Medical Service 16 Revue Internationale des Services de Santé des Forces Armées sickness. To minimize the adverse effects of chamber 5 RICE GM, VACCHIANO CA, MOORE JL, ANDERSON DW. exposure we changed the used protocols in order to Incidence of decompression sickness in hypoxia training limit the time spent at altitude and check the trainees with and without 30-min O2 prebreathe. Aviat Space before the session. To assess the safety of altitude Environ Med. 2003;74:56-61. chamber training we reviewed the outcome of 1,254 6 SMART TL, CABLE GG. Australian Defence Forces hypoba- military flight crews and paratroopers who were trai- ric chamber training, 1984¬2001. ADF Health. 2004;5:3-10. ned from year 2003 to 2009. We found 32 cases of adverse effects with an overall prevalence of 2.6%. 7 OHRUI N, TAKEUCHI A, TONG A, OHUCHI M, IWATA M, SONODA H, YAMASAKI S, AKASAKI S, HKAMATA N, Decompression sickness accounted for one case with a OHASHI K, NAKAMURA A. Physiological incidents during prevalence of 0.08%. Barotrauma, mainly involving the 39 years of hypobaric chamber training in Japan. Aviat middle ear, was recorded in nine cases with a preva- Space Environ Med. 2002;73:395-398. lence of 1.5%. We found also four cases of syncope (prevalence 0.3%). Because our population is limited 8 DeGROOT DW, DEVINE JA, FULCO CS. Incidence of and the results are not comparable with other works, adverse reactions from 23,000 exposures to simulated ter- our data suggest further investigations. restrial altitudes up to 8,900 m. Aviat Space Environ Med. 2003;74:994-997.

REFERENCES 9 DAVENPORT NA. Predictors of barotraumas events in a Navy altitude chamber. Aviat Space Environ Med. 1 DULLY FE. Altitude chamber training: is it worth the risk?. 1997;68:61-5. Hum Fac Aviat Med. 1992;39(5):1-8. 10 SAUSEN KP, WALLICK MT, SLOBODNIK B, CHIMIAK JM, 2 STEPANEK J. Decompression sickness. In: DeHart RL, BOWER EA, STINEY ME, CLARK JB. The reduced oxygen rd Davies JR. Aerospace Medicine. 3 Edition. Lippincott breathing paradigm for hypoxia training: physiological, Williams & Wilkins. 2002;67-98. cognitive, and subjective effects. Aviat Space Environ Med. 2001;72:539-545. 3 PIWINSKI S, CASSINGHAM R, MILLS J, SIPPO A, MITCHELL R, JENKINS E. Decompression sickness over 63 months of 11 ARTINO AR, FOLGA RV, SWAN BD. Mask-on hypoxia trai- hypobaric chamber operation. Aviat Space Environ Med. ning for tactical jet aviators: evaluation of an alternate 1986;57:1097-1101. instructional paradigm. Aviat Space Environ Med. 2006;77:857-863. 4 BASON R, YACAVONE D. Decompression sickness: U.S. Navy altitude chamber experience 1 October 1981 to 12 AL-WEDYAN IA, SHAIN BH, ABU GOSH HM, AL-AQQAD 30 September 1988. Aviat Space Environ Med. SS, AL-QURA’AN MS. Physiological training in Jordan. 1991;62:1180-1184. Aviat Space Environ Med. 1996;67:882-884.

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International Review of the Armed Forces Medical Service 17 Revue Internationale des Services de Santé des Forces Armées PROSTATE CANCER IS THE MOST WIDESPREAD CANCER FOR MEN - HEAD-MOUNTED OPERATING MICROSCOPE REVOLUTIONIZES UROLOGY

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International Review of the Armed Forces Medical Service 18 Revue Internationale des Services de Santé des Forces Armées An Unusual Case of Firearm Injury to the Face with Bullet Cover Lodged in the Nose.* ARTICLES ARTICLES ARTICLES ARTICLES

By S. AL SAIF❶ and K. AL-SHAIKH❷. Kingdom of Saudi Arabia

Saud AL SAIF

Colonel (DR) Saud AL SAIF, Director and Head of ENT Department Department Medical, King Fahd Military Medical Complex, Dhahran, Kingdom of Saudi Arabia.

RÉSUMÉ Une blessure inhabituelle de la face par arme à feu, avec une balle logée dans le nez. Nous décrivons un cas inusité d’une blessure accidentelle par arme à feu, chez un homme âgé de 35 ans, moniteur de tir, provo- quée par l’éjection d’une douille de cartouche, cette dernière venant s’encastrer dans la cavité nasale droite, à la limite du sinus sphénoïde, sans conséquence neurologique. L’extension des dommages tissulaires et la profondeur de la blessure ont été éva- luées par radiographie et CT scanner. La douille a été extraite sous contrôle endoscopique et la blessure a été suturée avec une petite perte de substance qui sera reprise ultérieurement lors d’une opération de chirurgie plastique reconstructive. L’évolution de la blessure a été favorable, avec un bon résultat esthétique. Ce cas montre que le traitement primaire des blessures par arme à feu, la réduction des bords de la plaie et l’usage régulier de pansements gras, sont la clef d’une bonne guérison.

KEYWORDS : Firearm injury, Bullet cover, Nose, Treatment. MOTS-CLÉS : Blessure par arme à feu, Douille, Nez, Traitement.

INTRODUCTION firearm trainer in army of KSA, who presented in the casualty of KFMMC on 3rd of November 2007, complai- Facial gunshot injuries are unusual and complicated ning of gunshot cover injury to the face fired in a clinical entities. The incidence of gunshot wounds to retrograde manner. the face has increased during past decades1-3. The past decade, 1500 Americans have died annually from On arrival, the patient was conscious, walking, anxious, unintentional gunshot wounds. Unintentional guns- and complaining of facial pain, nasal bleeding and hot wounds accounted for 20% of all nonfatal firearm blurred vision in his right eye with excessive tearing. He related injuries4. There is controversy regarding ideal did not have any history of loss of consciousness or time and method of reconstruction5-7. Some authors vomiting. believe that because of the mechanism of injury, early aggressive primary reconstruction might not be ideal. Initial conservative management followed by staged ❶ Col. Dr. secondary reconstruction could be performed to Dep. Medical, Director and Head of ENT department, King Fahd Military Medical Complex, Dhahran, Saudi Arabia. obtain satisfactory functional and aesthetic results5. ❷ Consultant ENT, While some showed early management of facial King Fahd Military Medical Complex, Dhahran, Saudi Arabia. 6 deformity . However there is consensus about the four Correspondance: main steps in the management of patients with guns- Col. Dr. Saud Al Saif King Fahd Military Complex hot wounds to the face: securing on airway, control- PO Box 14522 ling hemorrhage, identifying other injuries, and repair Damam 31434 Kingdom of Saudi Arabia 1, 9 of the traumatic facial deformities . Tel: +966-505613888 Fax: +966-840 5941 CASE REPORT E-mail: [email protected] * Presented at the 38th World Congress on Military Medicine, VOL. Kuala Lumpur, Malaysia, 4-9 October 2009. 83/3 We present an unusual case of a 35-years-old male

International Review of the Armed Forces Medical Services 19 Revue Internationale des Services de Santé des Forces Armées On examination he was fully conscious, oriented, Figure 2a: X-ray nose lateral view showing bullet cover hemodynamically stable without any hemorrhage or lodged in the right nostril just reaching sphenoid sinus. neurological deficit. Face showed laceration of the tip of nose with full thickness skin loss about 1 x 1 cm over right nostril with burned out edges, a small pedicle of ala was there (Figure 1) and the bullet cover was seen lodged in right nostril. There was mild postnasal bleeding. Small pledgets were seen lodged in skin of face on right side. On ophthalmology consultation foreign body in right eye was seen with congestion.

X-ray nose AP and lateral view showed bullet cover lodged in the right nostril, no fractures noticed. CT scan of head & sinuses showed a bullet cover in right nostril just reaching sphenoid sinus (Figure 2a, b), mild opacifications of both maxillary sinuses was seen but no fracture or any intracranial or cervical injury seen.

The patient was admitted in department of ENT. Under General Anaesthesia, using 300 and 700 scope Figure 2b: CT scan of head & sinuses showed a bullet cover left nostril was inspected, mucosa was intact, septum in right nostril just reaching sphenoid sinus. was shifted to the left side, and the base of bullet cover was seen through posterior choana on right side. Bullet cover was identified & removed by pulling with an artery with some difficulty (Figure 3), minimal blood loss was suctioned. Because of bullet cover septal mucosa on right side was raised and > 40% of middle turbinate was macerated. Septal mucosa was repositioned; Septum was repositioned using nasal speculum. The alar defect was approximated and surrounding skin undermined and defect repaired by placing a guiding suture without tension. Rounded defect about 0.6 x 0.5 cm left for healing with secondary intention putting in mind the possibility for the second step reconstruction in case of permanent defect. Bilateral internal nasal splints inserted. Bilateral merocel packs were inserted. Surgery went smoothly with no complications.

Foreign body right eye was removed without any com- plication with 6/6 vision.

Figure 1: The entry wound of the bullet cover with laceration Figure 3: Bullet cover removed by pulling with an artery. of the tip of nose with full thickness skin loss about 1 x 1 cm over right nostril with burned out edges, also pledgets can be seen lodged in cheek.

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International Review of the Armed Forces Medical Services 20 Revue Internationale des Services de Santé des Forces Armées On 3rd post op. day nasal packs were removed, there good results6. Undermining of the edges of wound and was no active bleeding or CSF rhinorrhoea, wound was regular lubricated dressings are key to good healing13-15. clean, the defect had approximated by more than 50%. We were able to keep the wound in good condition Well-lubricated open dressing was done every other by doing well-lubricated dressings preventing crust day, to prevent crust formation. The splint was remo- formation, and this helped in epithilization of wound. ved after 2 weeks; wound had healed by 80% both Avoiding the crust formation prevented dipping/ nasal cavities had healed well without any stricture or notching of the skin of nasal tip. septal perforation. On 4 months follow up the wound had healed completely (Figure 4). No external nasal CONCLUSION deformity was seen. Both nasal cavities and septum had healed well. There is only small synachae on right side The present case is unusual in the sense that it was cau- between septum and remnant of middle turbinate sed by bullet cover fired in a retrograde manner.

Figure 4: Completely healed wound seen at Although we found >100 recent case reports of guns- 4 months follow up. hot injury to the face but our case can be documented as the first such case since no similar cases are reported on review of literature. We demonstrated that early intervention can give good results.

Undermining of the edges of wound and well-lubricated dressings every other day are key to good healing. From the case we can also emphasis the importance of teaching principles of ballistics along with firearm training to the soldiers, so that such incidents can be avoided.

SUMMARY We report an unusual case of an accidental firearm injury, in 35-year-old male firearm trainer, by a bullet cover fired in a retrograde manner, which was lodged in right nasal cavity just reaching sphenoid sinuses without any neurological impairment. The extent of tissue damage and posterior extent of tract was asses- DISCUSSION sed by plain radiography and CT scans. The bullet cover The extent of tissue damage in gunshot wounds was recovered under endoscopic guidance and wound depends on the distance at which the gun is fired, mis- sutured with a small defect left for healing with secon- sile track, and bullet structure, size and velocity9-12. In dary intention keeping in mind second step reconstruc- our case the velocity of bullet cover was not much as it tion for permanent defect. On follow up wound had was fired in retrograde manner and size of bullet cover healed with good esthetic results. The case showed was very big, that’s why it did not penetrate deep to that gunshot injuries can be treated primarily and reach deeper structures. Because of size and velocity undermining of the edges of wound and regular well- there were thermal burns all around the bullet cover lubricated dressings are key to good healing. entry. REFERENCES According to Bailey, in the defects of nose tissue loss of 11. DEMETRIADES D, CHAHWAN S, GOMEZ H, FALABELLA A, <5 mm2 can be repaired primarily, whereas those VELMAHOS G, YAMASHITA D. Initial evaluation and >5 mm2 are best repaired with composite auricular management of gunshot wounds to the face. J Trauma grafts or local flaps or skin grafts. Alar rim defects are 1998; 45:39–41. most difficult to repair and the thin epithelial sleeve 12. REISS M, REISS G, PILLING E. Gunshot injuries in the head- make this area vulnerable to notching and contour irre- neck area: basic principles, diagnosis and management. gularities following reconstruction13, 14. Local wound Schweiz Rundsch Med Prax 1998; 87: 832–838. care post operatively is of outmost importance. By kee- 13. PUZOVIC D, KONSTATINOVIC VS, DIMITRIJEVIC M. ping wound bed moist and preventing formation of Evaluation of maxillofacial weapon injuries: 15-year dry eschar, prompt and favorable healing can be achie- experience in Belgrade. J Craniofac Surg 2004; 15: ved because it reduces the risk of infection and has 543–546. shown to increase the speed of epithilization because if kept moist epithelium seeks a plane of migration with 14. SINAUER N. Unintentional, Nonfatal Firearm-Related a critical humidity15. Guiding sutures can be employed Injuries: A Preventable Public Health Burden. JAMA. 1996, to partially close small defects and allows remainder to 275, 1740. 13 heal secondarily . 15. LONG V, LO LJ, CHEN YR. Facial reconstruction after a VOL. complicated gunshot injury. Chang Gung Med J. 2002; 25: 83/3 We demonstrated that early intervention can give 557-562.

International Review of the Armed Forces Medical Service 21 Revue Internationale des Services de Santé des Forces Armées 16. HOLLIER L, GRANTCHAROVA EP, KATTASH M. Facial guns- 11. STEWART MG. Penetrating face and neck trauma. In: Byron hot wounds: a 4-year experience. J Oral Maxillofac Surg. J, (editor). Bailey’s head and neck surgery – otolaryngology. 2001; 59: 277–282. Lippincott Williams and Wilkins, 2001: pp. 813–821.

17. SIBERCHICOT F, PINSOLLE J, MAJOUFRE C, BALLANGER A, 12. HAUG RH, LEXINGTON KY. Ballistic injuries of the maxillo- GOMEZ D, CAIX P. Gunshot injuriesof the face. Analysis of facial region. J Oral Maxillofac Surg 2002; 60: Suppl. 1. 165 cases and reevaluation of the primary treatment. Ann Chir Plast Esthet. 1998; 43: 132–140. 13. STEPHEN SP. Nasal restoration with flaps and grafts. In: Byron J, (editor). Bailey’s head and neck surgery – otola- 18. PERRY CW, PHILLIPS BJ. Gunshot wounds sustained inju- ryngology. Lippincott Williams and Wilkins, 2001: pp. ries to the face: a university experience. Internet J Surg 2425-2427. 2001; 2: 1–10. 14. RANDALL JJ, KAREN HC. Management of soft tissue 19. OSBORNE TE, BAYS RA. Pathophysiology and manage- trauma and auricular trauma. In: Byron J, (editor). Bailey’s ment of gunshot wounds to the face. In: Fonseca RJ, head and neck surgery – otolaryngology. Lippincott Walker RV (eds). Oral and maxillofacial trauma. WB Williams and Wilkins, 2001: pp. 944-945. Saunders, 1991: pp. 672–701. 15. MARCELO H, RICARDO AB. Nasal restoration with flaps 10. YETISER S, KAHRAMANYOL M. High-velocity gunshot and grafts. In: Byron J, (editor). Bailey’s head and neck wounds to the head and neck: a review of wound ballistics. surgery – otolaryngology. Lippincott Williams and Mil Med 1998; 163: 346–351. Wilkins, 2001: pp. 2.

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By Y. S. CHOI❶ and J. C. NANCE❷. U.S.A.

Young Sammy CHOI

PERSONAL INFORMATION Date of Birth: October 7, 1960. Professional address: Departments of Medicine and Pediatrics, Womack Army Medical Center, Fort Bragg, North Carolina 28310. Professional phone number: Department of Medicine (910) 907-8583/8385, Department of Pediatrics (910) 907-7337/6471. Professional email address: [email protected]

Director, Department of Research, Womack Army Medical Center, Fort Bragg, North Carolina (2008-present). Deputy Director, Graduate Medical Education (2006-present). Consultant, Departments of Medicine and Pediatrics (1989-present). Director, Continuing Medical Education, Womack (2008-present). Director, Womack Army Medical Center Grand Rounds (2006-present). Diabetes Program Manager (2007-present). Director, Pediatric Diabetic Clinic (2008-present). Consultant to Perinatal Diabetes Program, (2003-present). Education Fund Manager, Graduate Medical Education, Womack (2008-present). Education Fund Manager for Department of Pediatrics (1999-present). Education Fund Manager for Department of Medicine (2004-present). Physician in Charge of Pediatric Cardiology Testing (1990-2001, 2005-present).

MILITARY SERVICE - Army Health Professions Scholarship Program, August 1981 - June 1985 (Officer’s Basic Training, Fort Sam Houston, TX, June 1982 - July 1982; McDonald Army Community Hospital, Ft. Eustis, VA, June 1983 - July 1983; Brook Army Medical Army Medical Center, San Antonio, TX, May 1984 - June 1984). - William Beaumont Army Medical Center, El Paso, TX, Internship and Residency, July 1985 - June 1989. - Staff Internist & Pediatrician, Womack Army Medical Center, Ft Bragg, NC, July 1989 - June 1993. - Battalion Surgeon, 3rd Battalion, 504th Parachute Infantry Regiment, 82nd Airborne Division, Operation Desert Shield/Storm, August 1990 - April 1991.

RÉSUMÉ Sécurité de l’envoi en opérations de soldats atteints de diabète de type I. Lors de la dernière décennie, il est clairement apparu que le fait de porter un diagnostic de diabète de type I ne constituait pas en soi une cause d’inaptitude à de nombreuses activités parmi lesquelles le sport de compétition. De la même façon et bien que par le passé le diabète de type I ait pu être considéré comme incompatible non seulement avec un emploi opérationnel mais de façon plus générale avec le service armé, les soldats des Etats-Unis qui sont dans ce cas peuvent aujourd’hui être maintenus aptes et même être projetés au prix du strict respect de certaines conditions. L’intensité de l’activité physique rencontrée dans de nombreuses circonstances de la vie d’un athlète se rapproche de celle que connaît un soldat lors des activités d’entraînement ou de combat. C’est pourquoi le contrôle de la glycémie en cours d’effort constitue un excellent modèle pour prédire l’aptitude d’un soldat à être employé en opérations. Ceci étant admis, nous présentons 4 clés pour un emploi opérationnel réussi : compréhen- sion de l’effet de l’activité sur la maîtrise de la glycémie, emploi d’un système d’enregistrement continu de la glycémie, emploi de pompes à insuline à injection continue et possibilité de recours à des soins médicaux même en zone isolée.

VOL. KEYWORDS: Type 1 diabetes mellitus, Soldiers, Military, Qualification, Deployment. 83/3 MOTS-CLÉS : Diabète de type I, Soldats, Militaires, Aptitude, Opérations.

International Review of the Armed Forces Medical Services 24 Revue Internationale des Services de Santé des Forces Armées In the past decade, it has become clear that the diagno- high intensity activity that is typical of most team sis of type 1 diabetes in and of itself is not a disquali- sports16. For instance, we have found that competitive fying factor for most activities, to include competitive high school basketball and soccer players tend to have sports. Such notable athletes as Olympians Sean Busby an increase in glucose levels even if pre-exercise pran- (snowboarding) and Gary Hall (gold medal swimmer), dial insulin is not reduced (unpublished data). National Basketball Association player and former National College Player of the Year Adam Morrison, The American Diabetes Association in their most recent National Football League quarterback Jay Cutler, and position statement on exercise recommends blood glu- ultra-endurance runner Ayden Byle all attest to the abi- cose monitoring in order for the individual to learn the lity of type 1 diabetics to perform extremes of exercise glycemic affects of various types of physical activity17. in a safe manner. As for the athlete, these physical activities for the soldier should be evaluated in terms of duration, intensity, Similarly, though type 1 diabetes mellitus may have and whether it is intermittent or continual. For exam- been in the past considered incompatible not only with ple, type 1 diabetics may be involved in intermittent military deployment but military service in general, U.S. high intensity activities such as hand to hand combat or Army soldiers can now be retained and even deployed they may be involved in ultra endurance events such as if strict criteria are met1. The intensity of physical acti- the ironman triathlons6. Additionally, other factors such vity required of athletes in many ways mimics that of as hydration status, baseline blood glucose level, and soldiers during training or combat and therefore glyce- ambient temperatures should also be considered. mic control during exercise is an excellent model from Therefore, though protocols may offer a starting place which to evaluate a soldier’s qualifications for deploy- to guide insulin and carbohydrate use during exercise, ment. With this in mind, we present four keys to suc- the most important approach to take is that of indivi- cessful deployment: comprehension of the effects of dualized therapy9-10, 12. extreme activity on glucose control, continuous glucose monitoring, continuous subcutaneous insulin infusion CONTINUOUS GLUCOSE MONITORING pump, and availability of definitive medical care in remote locations. One of the novel technologies available to greatly assist soldiers with individualized therapy is continuous EXTREME ACTIVITY AND GLYCEMIC CONTROL glucose monitoring. Currently, four sensors are available with common features such as the ability to report Perhaps the greatest fear in athletes and deployed sol- real time glucose values at least every five minutes and diers is that of hypoglycemia2. During 60 minutes of the presence of alarms when high or low thresholds are high intensity cycling at 70% VO2max, hypoglycemia exceeded. Use of these sensors has been shown to improve glycemic control and to decrease time spent in occurred in two-thirds of subjects when bolus insulin hypoglycemia18-22. The greatest benefit may be in pre- dosage was not modified. Hypoglycemia was preven- dicting hypoglycemia and hyperglycemia in subsequent ted if bolus pre-exercise insulin was reduced by 50- similar activities and therefore modifications in insulin 90%3. For basal insulin, reduction in dose may not be and/or diet can be made23. necessary for shorter duration high intensity exercise4. However for ultra endurance exercise, such reductions Given the highly individualized response of soldiers to are typically necessary. For instance, in one study of insulin, we consider continuous glucose monitoring four cyclists competing in a 24 hour endurance relay routine therapy. For instance, we have observed that race, a 66% reduction in basal insulin was required in soldiers with nearly identical body mass index and acti- addition to 50% reduction in bolus insulin in order to vity level may require a 3-fold difference in insulin avoid significant hypoglycemia5. Similarly, in ironman dosage (unpublished data). Furthermore, it is hard to triathlons (2.4 mile swim, 112 mile bike, 26.2 mile run), predict accurately the glucose response to exercise24-25. a 50% reduction in basal insulin was required to prevent Therefore, our approach is to have soldiers undergo in hypoglycemia6. the pre-deployment state, a wide variety of activities to Several reviews on exercise in type 1 diabetes have 7-13 been published . Additionally, various protocols exist ❶ MD, FAAP, FACP to help predict the adjustment in insulin dosing that Departments of Medicine and Pediatrics Womack Army Medical Center can be used to prevent exercise induced hypoglycemia. Fort Bragg, North Carolina 28310. A reasonable starting point may be to reduce the pre- ❷ RD, LDN, CDE, CPT meal short-acting insulin by 50% if exercising at 50% Department of Medicine Womack Army Medical Center VO2max for 30 minutes or by a reduction of 75% if Fort Bragg, North Carolina 28310 7, 14 exercising at 75% VO2max for 30 minutes . Even those * Presented at the 38th World Congress on Military Medicine, Kuala Lumpur, Malaysia, 4-9 October 2009. who advocate carbohydrate replacement as being # The authors attest: more important than insulin adjustment recommend at -The views expressed herein are those of the authors’ and not to be least a 20-30% reduction in insulin dose for exercise las- construed as representing the official views of the United States Department ting greater than 60 minutes15. However, while this may of the Army or Department of Defense. -There are no sources of financial interest or potential conflicts of interests. VOL. -There are no sources of commercial or proprietary interest in any company, be true for continual moderate to high intensity exercise, 83/3 it may not necessarily apply to intermittent moderate to drug, device, or equipment mentioned in the submitted article.

International Review of the Armed Forces Medical Services 25 Revue Internationale des Services de Santé des Forces Armées include extremely strenuous aerobic and muscle condi- known amount of a carbohydrate meal without pro- tioning exercises which should include both continuous tein or fat is ingested. As before, the same conditions and intermittent approaches. This is in addition to the exist for the pre- and post-test four hour period. The normal training that is required to simulate conditions glucose obtained over the next 2-3 hours can be used encountered during deployment. During these training to determine if the ICR was accurate. This test is not periods, the use of continuous glucose monitoring pro- performed if the subject is sick and it is discontinued if vides extremely valuable information that allows the hypoglycemia occurs or if hyperglycemia above 19 soldier to predict subsequent glycemic effect to various mmol/L is present. Prediction models for estimating ISF activities. While, the variability between individuals may and ICRs are available such as the « Rule of 1700 » and be high, the individual response to a given activity tends « Rule of 500 » but all require verification to determine to be predictable. Furthermore, while devices in the accuracy. Use of a sensor is obviously simpler than mul- past were not real time sensors, current sensors not only tiple fingerstick glucose determinations. provide predictive abilities obtained during the testing period but also allow for simultaneous treatment. Finally, continuous glucose monitoring can be beneficial to verify nutritional requirements during strenuous As mentioned above, hypoglycemia is a major concern activities. The delicate balance is to not only prevent with type 1 diabetics. Nocturnal hypoglycemia is parti- hypoglycemia but also to provide enough fuel during cularly problematic since many patients may have pro- strenuous activity, particularly if prolonged, all the longed undetected hypoglycemia and may awaken while preventing hyperglycemia and the subsequent only if the episodes are severe. Such nocturnal hypogly- risk for acute metabolic complications of diabetic cemia has been associated with daytime fatigue26 and ketoacidosis. In a joint position statement released by may occur as a result of daytime high intensity exer- the American College of Sports Medicine, American cise27. Furthermore, a single episode of any hypoglyce- Dietetic Association, and Dietitians of Canada, the mia may blunt subsequent counter-regulatory response recommended hourly carbohydrate consumption to hypoglycemia28-29. This is particularly problematic during exercise for any athlete, i.e., not specifically dia- with exercise that occurs within 24-48 hours of a hypo- betic, was 30 to 60 gm per hour30. At least 40 grams of glycemic event as the risk for hypoglycemia is much glucose per hour of exercise has been recommended by greater. Regardless of when it occurs, continuous glu- some to prevent hypoglycemia specifically in diabetic cose monitoring can be extremely important for those athletes31-32; others have recommended up to 80 grams who have had or because of lifestyle are at particular per hour8 or 1 gm/kg/hour7. Careful attention to the risk for hypoglycemia. type of exercise and amount of carbohydrate consumed before, during, and after exercise can provide a Another use of continuous glucose monitoring is to predictable model for subsequent similar exercise. As evaluate the effects of supplemental boluses used to before, the use of a continuous glucose sensor can be correct high glucose values (correction bolus) or to pre- beneficial to tailor precise intake. vent the hyperglycemic response to a carbohydrate load (meal bolus). We use only rapid-acting insulin ana- CONTINUOUS SUBCUTANEOUS logues for this purpose due to their greater predictabi- lity. Soldiers are given education regarding insulin pro- INSULIN INFUSION PUMP files and causes of glucose fluctuations. Such education Insulin delivery continues to be a burdensome issue for includes the following: a) In general, these rapid-acting many diabetics. Given the austere environment that analogues have an onset of action within 10-15 soldiers not infrequently find themselves in, basal- minutes of injection, peak at about 1 hour and have a bolus therapy which is the standard for all type 1 dia- duration that lasts approximately 4 hours; b) betics, may pose logistical issues. Typically, such therapy Hypoglycemia typically results from either increased requires at least five injections per day (one basal plus activity (increased glucose utilization) or excess insulin; an additional four supplemental boluses) to maintain c) Hyperglycemia results from carbohydrate intake, lack optimal control. The advent of the continuous subcuta- of insulin, or stress (counter-regulatory hormones). Our neous insulin infusion pumps has made insulin delivery protocol to verify supplemental boluses can then be much less cumbersome. Currently, seven pumps have implemented as follows: Upon awakening, if the glu- been approved for use in the United States, one has cose is high, a correction bolus is given utilizing their been approved but not released, and a final one has given insulin sensitivity factor (ISF). For the next four been submitted for approval. hours, no carbohydrate source is ingested, no other supplemental bolus is utilized, and no activity above Insulin pumps provide continuous basal delivery typi- baseline is performed. Furthermore, the previous four cally in increments of 0.05 units per hour and bolus the- hours should also be free of any other supplemental rapy is usually given in increments of 0.05 to 0.1 units bolus, increased activity, or carbohydrate intake. The per hour. All allow insulin delivery for at least 72 hours. glucose obtained over the next 2-3 hours can be used Other usual features are alarms for occlusions and to determine if the ISF was accurate. Subsequent tests when battery or insulin reserve is critically low. A com- can be used to validate the results. Similarly, the insulin puterized algorithm allows for automatic calculations to carbohydrate ratio (ICR) can be verified. Whenever of supplemental boluses based on programmed insulin- VOL. the pre-meal glucose is in the normal range (thereby carbohydrate ratios and insulin sensitivity factors. An 83/3 negating the need for a correction bolus), a precise extremely helpful feature is the ability of some pumps

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Tools for professionals. www.instrumentariumdental.com to prevent insulin stacking that may occur when a cor- CONCLUSION rection bolus occurs within the expected duration of action of a previous bolus. By automatically reducing In conclusion, type 1 diabetes, though a medically the correction bolus based on the calculated amount reportable condition, is no longer an automatic disqua- of previous bolus insulin that is still active, hypoglyce- lification from military service. Furthermore, some sol- mia can be prevented. In addition to these safety fea- diers may even meet deployment criteria. An unders- tures, the obvious practical advantage to the soldier is tanding of the concepts surrounding hypoglycemia that there is no longer a requirement to give multiple and the technologic advances afforded through conti- daily injections as all insulin is delivered via the infusion nuous glucose monitoring, continuous subcutaneous set. insulin infusion pumps, and remote download capabilities all enhance the soldier’s ability for a safe and pro- DEFINITE MEDICAL CARE ductive deployment. AT REMOTE LOCATIONS SUMMARY The other important consideration in the safe deployment of diabetic soldiers is the availability of medical In the past decade, it has become clear that the diag- professionals with requisite knowledge of diabetes. nosis of type 1 diabetes in and of itself is not a disqua- While treatment for acute diabetic emergencies may lifying factor for most activities, to include competitive be standard and available, the chronic management to sports. Similarly, though type 1 diabetes mellitus may include insulin adjustment and insulin pump manage- have been in the past considered incompatible not only ment requires more expertise than that which is rea- with military deployment but military service in gene- dily available. The technologic advancements provided ral, U.S. Army soldiers can now be retained and even by remote downloading of glucose meters and insulin deployed if strict criteria are met. The intensity of phy- pumps make this consideration less intimidating. With sical activity required of athletes in many ways mimics the use of electronic transmission and the ease of that of soldiers during training or combat and there- interrogating insulin pumps and sensors, data can fore glycemic control during exercise is an excellent easily be transmitted anywhere in the world. model from which to evaluate a soldier’s qualifications for deployment. With this in mind, we present 4 keys to We recommend all soldiers to use an insulin pump that successful deployment: comprehension of the effects of is compatible with a continuous glucose monitoring. extreme activity on glucose control, continuous glucose Currently, the only system with this capability is the monitoring system, continuous subcutaneous insulin MiniMed Paradigm Real-Time System/Paradigm infusion pump, and availability of definitive medical 522/722 (Medtronic Diabetes, Northridge, CA). This sys- care in remote locations. tem provides for download to a patient’s computer REFERENCES which can be subsequently electronically transmitted to the diabetic team. It also allows for synchronization 11. Army Regulation 40-501. Medical Services Standards of of data to a website which can be shared by the Medical Fitness. 10 September 2008. patient with their provider. Either way, the download 12. BRAZEAU AS, RABASA-LHORET R, STRYCHAR I, MIRCESCU provides for such information as glucose values and H. Barriers to physical activity among patients with type 1 sensor readings, quantity of carbohydrates counted, diabetes. Diabetes Care. 2008;31:2108-2109. amount of meal and correction boluses given, insulin pump settings, and the exact time the data was collec- 13. MAUVAIS-JARVIS F, SOBNGWI E, PORCHER R, et al. ted. Statistical data, graphs, summary sheets, and indi- Glucose response to intense aerobic exercise in type 1 dia- vidual day to day information are all readily available. betes. Diabetes Care. 2003;26:1316-1317. Additionally, it informs when and if the pump is sus- 14. PETER R, LUZIO SD, DUNSEATH G, et al. Effects of exercise pended. All soldiers who are deployable must demons- on absorption of insulin glargine in patients with type 1 trate knowledge not only in the technical aspects of diabetes. Diabetes Care. 2005;28:560-565. adjusting their insulin pump settings but they must 15. LARGAY J, McMURRAY R, SABBAH HT, BODE, BW. A pilot also demonstrate the ability to send downloads. study to determine the optimal insulin adjustment and carbohydrate supplementation to perform intense endu- We consider these four aforementioned principles as rance exercise in four cyclists with type 1 diabetes [abs- the keys to successful deployment. The final checklist tract]. Diabetes 2001;50 (suppl 2):A484. however includes many more considerations. As an example, The National Trainers’ Association provides 16. BOEHNCKE S, POETTGEN K, MASER-GLUTH C, REUSCH J, recommendations to the certified athletic trainer who BOEHNCKE WH, BADENHOOP K. Endurance capabilities is typically the first line of treatment for acute compli- of triathlon competitors with type 1 diabetes mellitus. cations of type 1 diabetes33. Our approach to this final Dtsch Med Wochenschr. 2009;134:677-682. checklist before deployment is continually modified by 17. GALLEN IW. Review: helping the athlete with type 1 dia- the experiences of soldiers who have deployed and betes. Br J Diabetes Vasc Dis. 2004;4:87-92. returned home. A deliberate education and training approach of soldiers, significant others to include col- VOL. 18. ELDER CL, PUJOL TJ, BARNES JT. Exercise considerations leagues, and known medical assets will contribute 83/3 for individuals with type 1 diabetes. Strength greatly to a safe and successful deployment. Conditioning J. 2004;26:16-18.

International Review of the Armed Forces Medical Service 28 Revue Internationale des Services de Santé des Forces Armées 19. MACKNIGHT JM, MISTRY DJ, PASTORS JG, HOLMES V, trancutaneous, real-time continuous glucose sensor. RYNDERS CA. The daily management of athletes with dia- Diabetes Care. 2006;29:44-50. betes. Clin Sports Med. 2009;28:479-95. 22. The Juvenile Diabetes Research Foundation Continuous 10. LUMB AN, GALLEN IW. Diabetes management for intense Glucose Monitoring Study Group. Continuous glucose exercise. Curr Opin Endocrinol Diabetes Obes. monitoring and intensive treatment of type 1 diabetes. N 2009;16:150-155. Engl J Med. 2008;359:1464-1476.

11. De FEO P, Di LORETO C, RANCHELLI A, FATONE C, 23. CAUZA E, HANUSCH-ENSERER U, STRASSER B, LUDVIK B, GAMBELUNGHE G, LUCIDI P, et al. Exercise and diabetes. KOSTNER K, DUNKY A, et al. Continuous glucose monito- Acta Biomed. 2006;77(suppl 1):14-17. ring in diabetic long distance runners. Int J Sports Med. 2005;26:774-80. 12. TONI S, REALI MF, BARNI F, LENZI L, FESTINI F. Managing insulin therapy during exercise in type 1 diabetes mellitus. 24. BIANKIN SA, JENKINS AB, CAMPBELL LV, CHOI KL, FORREST Acta Biomed. 2006;77(suppl 1):34-40. QG, CHISHOLM DJ. Target-seeking behavior of plasma glucose with exercise in type 1 diabetes. Diabetes Care. 13. LISLE DK, TROJIAN TH. Managing the athlete with type 1 2003;26:297-301. diabetes. Curr Sports Med Rep. 2006;5:93-98. 25. McNIVEN-TEMPLE MY, RIDDELL MC, BAR-OR O. The relia- 14. RABASA-LHORET R, BOURQUE J, DUCROS F, CHIASSON JL. bility and repeatability of the blood glucose response to Guidelines for premeal insulin dose reduction for post- prolonged exercise in adolescent boys with IDDM. prandial exercise of different intensities and durations in Diabetes Care. 1995;18:326-332. type 1 diabetic subjects treated intensively with a basal- bolus insulin regimen (ultralente-lispro). Diabetes Care. 26. KING P, KONG MF, PARKIN H, MACDONALD IA, 2001;24:625-630. TATTERSALL RB. Well-being, cerebral function, and physical fatigue after nocturnal hypoglycemia in IDDM. 15. GRIMM JJ, YBARRA J, BERNÉ C, MUCHNICK S, GOLAY A. A Diabetes Care. 1998;21:341-345. new table for prevention of hypoglycaemia during physi- 27. ISCOE KE, CAMPBELL JE, JAMNIK V, PERKINS BA, RIDDELL cal activity in type 1 diabetic patients. Diabetes Metab. MC. Efficacy of continuous real-time blood glucose moni- 2004;30:465-70. toring during and after prolonged high-intensity cycling exercise: spinning with a continuous glucose monitoring 16. GUELFI KJ, JONES TW, FOURNIER PA. New insights into system. Diabetes Technol Ther. 2006;8:627-635. managing the risk of hypoglycaemia associated with intermittent high-intensity exercise in individuals with 28. BRISCOE VJ, TATE DB, DAVIS SN. Type 1 diabetes: exercise and type 1 diabetes mellitus: implications for existing guide- hypoglycemia. Appl Physiol Nutr Metab. 2007;32:576-582. lines. Sports Medicine. 2007;37:937-946. 29. CAMACHO RC, GALASSETTI P, DAVIS SN, WASSERMAN 17. American Diabetes Association: Physical Activity/Exercise DH. Glucoregulation during and after exercise in health and Diabetes (Position Statement). Diabetes Care. and insulin-dependent diabetes. Exerc Sport Sci Rev. 2004;27(suppl 1):S58-S62. 2005;33:17-23.

18. DEISS D, BOLINDER J, RIVELINE JP, BATTELINO T, BOSI E, 30. American College of Sports Medicine, American Dietetic TUBIANA-RUFI N, et al. Improved glycemic control in Association, Dieticians of Canada. Nutrition and perfor- poorly controlled patients with type 1 diabetes using real- mance. Med Sci Sports Exerc. 2000;32:2130-2145. time continuous glucose monitoring. Diabetes Care. 2006;29:2730-2732. 31. DUBÉ MC, WEISNAGEL SJ, PRUD'HOMME D, LAVOIE C. Exercise and newer insulins: how much glucose supple- 19. HALVORSON M, CARPENTER S, KAISERMAN K, KAUFMAN ment to avoid hypoglycemia? Med Sci Sports Exerc. FR. A pilot trial in pediatrics with the sensor-augmented 2005;37:1276-82. pump: combining real-time continuous glucose monitoring with the insulin pump. J Pediatr. 2007;150:103-105. 32. JENSEN J. Nutritional concerns in the diabetic athlete. Curr Sports Med Rep. 2004;3:192-197. 20. GARG S, JOVANOVIC L. Relationship of fasting and hourly blood glucose levels to HbA1c values. Diabetes Care. 33. JIMENEZ CC, CORCORAN MH, CRAWLEY JT, HORNSBY 2006;29:2644-2649. WG, PEER KS, PHILBIN RD, et al. National Athletic Trainers’ Association Position Statement: Management of the 21. GARG S, ZISSER H, SCHWARTZ S, BAILEY T, KAPLAN R, athlete with type 1 diabetes mellitus. J Athl Train. ELLIS S, et al. Improvement in glycemic excursions with a 2007;42:536-545.

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Warner ANDERSON

Warner Anderson MD FACP, physician and medical anthropologist. Director of the International Health Division. International Health is responsible for health policy in stability operations and humanitarian assistance. Dr. Anderson is an Indian Health Service employee detailed to OASD(HA)/TMA, and is a retired US Army Reserve colonel. He joined the National Guard's 20" Special Forces Group (Airborne) at 17 years old, and left service 7 years later as a sergeant first class (E-7). He was a Special Forces engineer sergeant and medical sergeant, with additional designation in psychological operations. Dr. Anderson re-entered military service after an 18-year hiatus, commissioned a captain in the Army Medical Corps. He served 2 years as Chief of Internal Medicine for a Mobile Army Surgical Hospital. He also was Medical Consultant and volunteer instructor at the US Air Force Pararescue School, where he taught and participated in search missions for 7 years. Anderson served as Battalion Surgeon for a USAR Special Forces battalion. In September, 2001 Col. Anderson volunteered for a year of mobilization. He deployed to Operation Iraqi Freedom in March, 2003 with the National-Level Public Health Team of the 352"d Civil Affairs Command. He returned to Iraq in 2006, this time as Surgeon and combat medic for the Iraqi Counterterrorist Force. Col. Anderson's « one-year » mobilization ended after 5-112 years. He retired from the USAR and returned to the Indian Health Service, from which he was recruited for his present position. In civilian life, Anderson established 3 free clinics in the 1970's as a community advocate (two of these clinics are still providing care), while earning a Bachelor of Science degree in Behavioral Science at the University of South Florida. He completed Physician Assistant School, attended graduate school in bio- medical sciences. Dr. Anderson completed residency in Internal Medicine at the University of New Mexico. He worked for 2 years in the National Health Services Corps in Gallup, NM, with low-income Spanish-speaking patients. He worked in private practice general and critical care medicine for 2 years, then became Director of Emergency Medicine for a local non-profit hospital. He re-entered Civil Service as Chief of Emergency Medicine at the US Public Health Service's largest hospital, directing care for 85,000 Navajo Indian patients per year. He served as EMS Medical Director for the county and city, and a district of the Navajo Nation. Dr. Anderson has been recognized with Fellowship in the American College of Physicians, New Mexico EMS Physician of the Year, and other civilian awards. Email is warner.anderson @tma.osd.mil.

RÉSUMÉ Support médical des opérations de stabilité : nécessite de standards de soins. La notion d’opération de stabilité fait référence aux missions militaires menées en dehors des frontières nationales ayant pour but d’établir et de maintenir la sécurité en venant assurer les besoins essentiels et en apportant les secours d’urgence. En novembre 2005, le Department of Defense (DoD) éditait la directive DoD 3000.05 qui désignait les opérations de stabilité comme une mission centrale à laquelle tous les militaires américains devaient être préparés. Cet article fait une revue historique de l’engagement militaire américain dans ces opérations de stabilité qui embrassent un grand nombre d’activités allant des secours et de l’aide humanitaire à la reconstruction de l’état et à la contre-insurrection. Il plaide pour un examen systématique de toutes les leçons tirées du siècle passé concernant le rôle des militaires dans le soutien sanitaire et ouvre les pistes pour une diffusion de l’information autour de ces leçons et pour leur prise en compte dans les orientations politiques devant encadrer les futurs VOL. engagements militaires extérieurs. Cet article souligne aussi les efforts constants consentis par le DoD pour institutionnaliser 83/3 les interventions médicales et définir les directives adaptées applicables à ces missions.

International Review of the Armed Forces Medical Services 31 Revue Internationale des Services de Santé des Forces Armées KEYWORDS: Stability operations, U.S. Military, Medical support. MOTS-CLÉS : Opérations de stabilité, Armée des Etats-Unis, Soutien médical.

INTRODUCTION became engaged in a wide range of reconstruction and stabilization projects. The recent experiences of the U.S. military in Iraq and Afghanistan have spurred a renewed debate over the Throughout this period, U.S. military medical assets direct involvement of the military in health sector activi- played an important role in providing health care to civi- ties overseas. In fact, although not widely acknowledged, lian populations not only through direct care operations military engagement in medical stability operations has like vaccination campaigns, but also by building local been a recurring theme throughout U.S. history and the water and sanitation infrastructure to reduce disease development of the military. This article will review les- and protect the health of troops and natives alike5, 6. The sons learned throughout the last century of military impact of these efforts was reflected in the words of the health support to stability operations and develop ways to military governor of the Philippines at the time, incorporate these lessons into future policies for overseas Lieutenant General Arthur MacArthur, «Medical care military medical engagement. was significant in winning over the urban population, depriving the guerillas of their support base and supplies In 2008, the U.S. Army released FM 3-07, a field manual necessary to continue the fight and securing victory6». defining stability operations as «military missions and activities conducted outside the U.S. to establish and maintain Through the turn of the twentieth century, the U.S. security and stability through the provision of essential became involved in a number of conflicts in Latin services, emergency reconstruction, and humanitarian America to maintain and restore stability in the region. relief1.» When applied to the health sector, stability ope- During these conflicts, the US military actively employed rations are usually referred to as medical stability opera- its engineering and medical assets to build public health tions2. Despite a long history of providing humanitarian services in a number of countries including Haiti, the assistance during natural disasters and armed conflicts, Dominican Republic, Mexico, and Nicaragua4. The 19- the value of the military’s direct involvement in providing year long occupation of Haiti is just one example where health services has been viewed with skepticism, fueled by extensive public health programs carried out by U.S. mili- a lack of quantitative evidence (science) linking military tary forces helped to eliminate malaria and establish a health engagement to security and stability in those areas new standard for hygiene and health throughout the where they have been provided3. country. These military medical efforts contributed significantly to winning the trust and support of the local Nevertheless, military health engagements have always population and increasing stability in these countries4. been an essential component of any long term overseas engagement strategy. The U.S. military has great expe- The Small Wars Manual, which represents the distilled rience in conducting medical stability operations even wisdom of Marine Corps deployments during this though this knowledge has never been formally incorpo- period states, «The medical personnel with the force is rated into mainstream military thinking. This is in part due one of the strongest elements for gaining the confi- to the conventional military perception of medical opera- dence and friendship of the native inhabitants in the tions as subordinate to war fighting4. History provides a theater of operations. So long as it can be done different account; medical stability operations are a core without depleting the stock of medical supplies requi- military mission that have allowed the nation to maintain red for the intervening troops, they should not hesitate peace after winning each battle. to care for sick and wounded civilians who have no other source of medical attention.» It additionally The following historical overview is intended to highlight states that should «the campaign plan contemplate the longstanding military involvement in conducting medical organization of armed native troops, additional medi- stability operations, and to make the case for the need to cal personnel will have to be provided with the force or systematically document, study, and share the lessons lear- requested from the United States as required7». ned from past missions.

U.S. MILITARY EXPERIENCE IN ❶ International Health Division, Office of the Assistant Secretary of Defense (Health Affairs), MEDICAL STABILITY OPERATIONS Force Health Protection and Readiness. ❷ Henry Jackson Foundation & Center for Disaster and Humanitarian 1898 marks the beginning of formal U.S. military health Assistance Medicine, engagements in overseas missions. After the USS Maine Uniformed Services University of the Health Sciences. sank in Havana Harbor, the U.S. declared war on Spain ❸ Office of the Assistant Secretary of Defense (Health Affairs), Force Health Protection and Readiness. and quickly found itself in control of Cuba and Puerto Rico in the Caribbean, as well as the Philippines, and a Correspondance: Dr. Warner Anderson 4 number of small islands in the Pacific . But as some of the International Health Division, ASD-HA native population were not ready to accept the replace- 5113 Leesburg Pike, Suite 800A VOL. Falls Church, VA 22041 ment of a Spanish colonial master for an American, the [email protected] 83/3 U.S. was required to maintain an occupying force which Phone (703) 824 4310, Fax (703) 824 4328

International Review of the Armed Forces Medical Services 32 Revue Internationale des Services de Santé des Forces Armées After World War II, the U.S. employed its armed forces Unfortunately, the U.S. military’s best practices from pre- in numerous operations designed to bring stability to vious medical engagements were not always incorporated various countries and regions worldwide. And while the into contemporary planning. Despite clear guidance in the primary task of the medical and engineering units were Counterguerrilla Operations Field Manual to utilize «host to provide for the occupation forces, the specialized country medical resources and capabilities when available capabilities they brought with them were also used to and acceptable», and that «military medical support should rebuild the communities surrounding the bases and be terminated as soon as possible to avoid alienating civi- beyond. Germany, Japan, and Korea were among the lian doctors who might be deprived of their means of live- numerous countries impacted by such operations. lihood», this advice was not always followed. In a declassi- fied 1968 study conducted by the Department of the Army, In Japan for example, Brigadier General Crawford Sams many of the civic action programs in Vietnam had not wor- oversaw a number of health sector activities throughout ked because they had failed to fully involve the local popu- the country including nationwide public health programs lation; and because the Army lacked qualified personnel to to control the spread of various diseases as well as efforts plan, train, equip and advise host nation partners on inte- to reform the infrastructure of medical education8. In grated public health reconstruction and stabilization pro- Germany, the military supported humanitarian missions grams11. Despite these shortcomings, the tactical power of like the Berlin Airlift, which supplied not only medicines medical stability operations to engage the local population and hospital supplies, but fuel and food to roughly two continued to influence the development, implementation, million Berliners for nearly a year9. Evidence suggests that and transition to a modern concept of humanitarian assis- these activities not only contributed greatly to the physi- tance missions for deployed forces12. cal recovery of the country, but also served as a means to demonstrate American principles and values. In cases like Concerned with growing instability and the influence of the Berlin Airlift, the military’s operations provided a communism in Central America during the 1980’s, the launching platform for the formation of CARE, a non- U.S. Congress authorized and appropriated funds for governmental organization which would expand their military operations in the region, including a number of work from providing Cooperative for American MEDCAPs and national building exercises. Because of its Remittances to Europe (CARE)* packages to post-World geographic position, return to a democratic form of War II Berliners to covering a wide range of humanitarian government and strong relationship with the U.S., needs around the world today. Honduras was selected as a key beneficiary for a number of different U.S. government programs including Another example of a successful medical assistance pro- widespread USAID development assistance and, at the gram was conducted in Korea prior to the breakout of time, the largest Peace Corps mission in the world12, 13. By hostilities on the Korean peninsula. To counteract the 1983, American military forces established a permanent personnel shortage experienced when expatriate presence at Soto Cano Air Base, which became involved Japanese healthcare professionals returned home at in training health workers, immunizing a large segment the end of World War II, the U.S. Army established the of the rural population, and providing veterinary ser- Korean Army Medical Field Service School, which trai- vices to Honduran farmers. These Medical Readiness ned local Korean doctors and nurses. To further streng- Training Exercises (MEDRETE) and Immunization then the Korean medical infrastructure, the Readiness Exercises (IMRETE) offered peacetime enga- Department of Army created an opportunity for gement platforms to engage the local populations in Korean students to attend medical and nursing schools Honduras and the neighboring countries. in the U.S. Like the reconstruction and stabilization efforts being pursued today, these activities were cru- In cases where U.S. military medical personnel worked cial in strengthening host nation capacity to care for within existing national infrastructure and coordinated their own civilians which then allowed military medical their efforts with civilian colleagues, the benefits to the personnel to concentrate their efforts on troop care community were significant. Not only were improve- when the Korean War broke out in 19505, 6. ments in healthcare services sustainable but the long and continuous relationships cultivated good will During the Vietnam War, a variety of Medical Civic Action towards the United States amongst the population4, 5, 14. Programs (MEDCAPs) were conducted by the U.S. military to And while the primary aim of these activities was to assist the local population. The 1967 Counterguerrilla improve bilateral relations, they had the additional Operations Field Manual FM 31-16 notes that «the missions of benefit of creating regional coordination mechanisms to medical service in limited and general war operations and in respond to natural disasters, repair critical infrastructure, counterguerrilla operations are basically the same, except and improve high priority health and sanitation needs. that the demonstrated effectiveness of medical services in military civic action, either voluntary or directed, imposes on With the fall of the Soviet Union in 1991 and the the medical service resources vastly increased requirements10.» increasing number of Military Operations Other Than These programs not only included direct patient care, but War (MOOTW), military medical personnel were often important public health needs like potable water, improved tapped to conduct medical stability operations in places sanitation facilities, and disease prevention, as well as provi- like northern Iraq, the Balkans, Somalia, Haiti, and ding education and training to local health care providers5, 6. Kosovo5. Medical operations as part of a humanitarian VOL. and civic assistance operation were born, not only out 83/3 * http://www.care-international.org of obligations to international law or the realization

International Review of the Armed Forces Medical Service 33 Revue Internationale des Services de Santé des Forces Armées AQUILION ONE

The “Aquilion ONE” dynamic volume CT from Toshiba Medical Systems sets new standards in imaging diagnostics. The wish of physicians for the ability to scan the entire organ, e.g. the heart, brain or liver, in one rotation and hence in a fraction of a second, has now become rea- lity for the first time with the “Aquilion ONE”.

The dynamic volume computed tomography scanner is the first in the world to boast an anatomical coverage of 16 cm and 320 simultaneous slices. This innovation opens up a completely new dimension in the use of computed tomography, while the expanded dynamic volume diagnosis makes it highly patient-oriented.

The very low radiation exposure paves the way for applications in paediatric radiology, amongst other areas.

In neurology this system allows examination times to be shortened through volume acquisition, opens up new possibilities by its capacity to analyse dynamic processes and thereby reduces diagnostic risk.

Leading medical practitioners predict that the scanner will be particularly useful in cardiology, as it allows the entire heart to be captured live in just one heartbeat. In particular, the speed and stability of heart imaging are crucial to obtaining an optimal workflow and the best results.

The Aquilion ONE has the potential to drastically improve the quality of diagnosis while at the same time reducing costs for the healthcare system. Whereas patients exhibiting symptoms of a heart attack or stroke have until now normally had to submit to a variety of examinations preparatory to a precise diagnosis, all of which together took up a considerable amount of time, with the Aquilion ONE this can now be slashed to a matter of minutes and one single examination. Functional imaging can thus be performed rapidly, with the least possible radiation and contrast dose combined with very high precision.

The Aquilion ONE makes it possible for the first time to represent organs in three dimensions, thereby also enabling dynamic processes such as blood flow and function to be observed. The 16 cm of anatomical coverage using the parallel 320 ultra high-resolution 0.5 mm detector elements means that the Aquilion ONE, unlike previous CT scanners, can capture entire organs such as the heart and brain in just one rotation. This ability to carry out a complete examination in only 0.35 seconds eliminates the need to reconstruct data from several points in time and thereby significantly enhances diagnostic confidence.

The possibility of a uniquely comprehensive examination, including functional imaging, reduces the need for several additional and sometimes duplicative tests or invasive procedures. Thanks to this highly innovative technology, patients are spared unnecessary examinations, allowing costs to be slashed.

VOL. More information about the Toshiba Medical Systems and Aquilion ONE can be found at 83/3 http://www.toshiba-europe.com/medical/

International Review of the Armed Forces Medical Service 34 Revue Internationale des Services de Santé des Forces Armées that helping provide health care for the local popula- cooperate in rebuilding Sumatra, resulting in a cease- tion was essential to the long term reconstruction of fire and eventually a peace treaty, signed one year civil order, but also out of a belief that helping provide after the tsunami. health care to those in need reflected a fundamental American value which protected the sanctity of life. MEDICAL STABILITY OPERATIONS These values are most visible during the military’s sup- AROUND THE WORLD port to disaster response operations. The ability to provide essential services and improve In the 2004 tsunami response in Indonesia, U.S. military healthcare as a means to establish legitimacy, gain forces provided critical imagery and logistics assistance influence and win the hearts and minds of the popula- to the host nation, United Nations and NGO first res- tion, has replicated by other countries and non-state ponders that would have been otherwise unavailable. actors with great interest. In Southern Lebanon for With a comparative advantage in crisis action planning, example, Hezbollah effectively uses social services to the U.S. military supported the development of an strengthen its influence among the population in the international interagency multi-sectoral assessment south where it operates a network of clinics and hospi- team, which established a common baseline for huma- tals for disenfranchised segments of the population. nitarian needs. Throughout the assessment, USS After the war with Israel in 2006, Hezbollah’s reputa- Abraham Lincoln provided the full range of support to tion and influence improved significantly because it include feeding, housing, and transporting team mem- was able to immediately provide medical attention to bers across the island. These contributions allowed the those injured by the fighting including health care of Indonesian government and the United Nations to the internally displaced population17. minimize duplication of effort and prioritize the har- dest hit areas for immediate response. Since its conception Cuba18 has realized the crucial role health diplomacy can play in foreign policy. Four years But perhaps DoD’s largest medical contribution appea- after the establishment of the Republic of Cuba the red most visibly in the form of the USNS Mercy class government sent their first medical brigade of over 50 hospital ship15, a 890 foot long, 69,000 ton, 1,000 bed doctors and health care workers to the newly indepen- hospital ship. The two USNS hospital ships originally dent Algeria. Since then, Cuba has had a long standing designed for combat service support in a conventional history of employing its medical assets to build rela- conflict against an adversary who followed the Geneva tionships, win allies, and cultivate good will to gain Conventions are equipped with a full suite of medical greater access to aid, trade, and credit. More than 100 services to include: dental services, radiological services, countries worldwide have received different types of physical therapy, burn care, an intensive care unit, an medical assistance from Cuba including medical sup- optometry lab, and two oxygen producing plants. plies and equipment, training for medical personnel, However, with the fall of the Soviet Union and the virtual training programs for students, and disaster pre- rising number of overseas contingency operations, paredness training. Today, Cuba’s understanding of the these ships have increasingly proved their utility as value of medicine in gaining influence is reflected in its disaster response platforms. The disease surveillance, ongoing efforts to provide sustainable health develop- health needs assessment, and direct care capabilities ment in many poor and less developed countries, primarily provided by deployed military medical units and the throughout Latin America and Africa19. hospital ships highlighted the synergistic benefits of civil-military cooperation and laid the foundation for On the other side of the world, China also sent its first improved humanitarian assistance and disaster relief overseas medical assistance team to Algeria in 1963. efforts in later U.S. government responses in Pakistan, Since that time China has deployed an estimated Louisiana, and Haiti. 15,000 Chinese doctors to over 47 African countries treating some 180 million Africans20, 21. Emphasizing From a macroscopic perspective, the tsunami response relationship building and providing culturally appro- highlights the strategic security benefits of military priate health solutions, Chinese doctors normally spend health support to disaster response operations. In the two years in country, with many doctors making repeat first days after the tsunami humanitarian efforts were deployments. These efforts were expanded in the wake complicated not only by Free Aceh Movement (GAM) of the international response to the 2004 tsunami separatists who had been fighting for independence when China realized the benefits of using the Navy as since 1976 and opposed the arrival of additional mili- a medical and public health engagement platform. tary personnel in the area, but also by the Indonesian government which was sensitive to providing assis- In order to make the most of their medical outreach tance to the insurgents and wanted to control all relief. program, the Chinese military tailor built their Type 920 By concentrating on humanitarian needs rather than hospital ship22 from the keel up in contrast to the political divisions, U.S. military support to civilian American hospital ships, which were converted from oil authorities was available to mitigate the worst impacts tankers. While much smaller in tonnage than the Mercy of the disaster16 as well as provide a mechanism to dis- class hospital ships, the new Chinese hospital ship cuss larger political issues. As in the best outcomes of boasts much of the same equipment and has a CT VOL. disaster responses, the overwhelming needs of the peo- room, X-ray machines, an ICU intensive care monitoring 83/3 ple forced both the separatists and government to unit, ultrasonic emulsifying devices, type-B ultrasonic

International Review of the Armed Forces Medical Service 35 Revue Internationale des Services de Santé des Forces Armées instruments, ECG [electrocardiogram] machines, and the minds of the population, reduces morbidity and other medical testing devices making the ship equal in mortality, increases the human capital potential of the grade to a class A, level 3 hospital. With roughly 300 country, and bolsters the moral legitimacy of the beds, eight operating rooms and a flight deck for heli- American intervention. copter operations, the Chinese hospital ship should be capable of responding to a wide range of military In contrast, retributive justice as was attempted by the medical stability operations in the Pacific and beyond. Morgenthau Plan, which attempted to reduce Germany to an agrarian pastureland at the end of THE FUTURE OF MEDICAL World War II, only succeeded in halting the reconstruc- STABILITY OPERATIONS tion of Europe and driving populations to join the Soviet Union. It was only after the rehabilitative efforts A review of the U.S. military’s historical record high- of the Marshall Plan, which focused on assisting all lights the fact that medical stability operations are not those in need including former opponents like a deviation from conventional military missions but Germany and Italy, that the reemergence of a global rather an essential peace building component that has economy became possible. Not surprisingly, echoes of expanded to meet growing needs. The past military George Marshall’s famous declaration, «Our policy is medical counter-insurgency, humanitarian assistance directed not against any country or doctrine but and disaster response, and reconstruction and stabili- against hunger, poverty, desperation and chaos» can be zation efforts, while sometimes discursive have all heard throughout National Security Policy Directive – played a substantial role in the long term successes of 44 (NSPD-44). U.S. military campaigns. And as the U.S. government policy evolves to include a comprehensive global health Published in 2005 after the military defeat of Taliban in security strategy to utilize all elements of national Afghanistan and Saddam’s government in Iraq, NSPD- power, military medical «soft-power» options will 44 recognized that, «The U.S. has a significant stake in continue to increase in importance and frequency. enhancing the capacity to assist in stabilizing and reconstructing countries or regions, especially those at The role of military medical stability operations in the risk of, in, or in transition from conflict or civil strife, U.S.’s efforts to promote stability and security abroad and to help them establish sustainable path toward are growing. For millennia, first generation war has peaceful societies, democracies and market econo- been focused on enslaving human manpower to till the mies.» Rather than regarding medical stability opera- soil and provide manual labor to ease the burdens of tions as a gift or act of charity, they are recognized for the conqueror’s life. The Industrial Revolution mecha- their utilitarian benefits. NSPD-44 points out, «Such nized many labor-intensive tasks refocusing second work should aim to enable governments to exercise generation war on controlling the resources needed to sovereignty of their own territories and to prevent keep the engines turning like iron, oil, coltan, and tita- those territories from being used as a base of opera- nium. But with the dawn of the Information Age and tions or safe haven for extremists, terrorists, organized the increased importance of accessing a diverse of crea- crime groups, or others who pose a threat to U.S. tive intellectual streams, third generation war reco- foreign policy, security, or economic interests.» While gnizes that intellectual freedom necessitates winning the first generation war defines sovereignty as the ulti- the trust and voluntary support of the local population mate control of violence, third generation war legiti- by showing an improvement in their quality of life. In macy rests on its ability to protect the health and lon- this equation, support for medical stability operations gevity of the affected population. to increase the health and longevity of the host nation’s population can be viewed as a hard-nosed eco- DoD Directive 3000.05 initiated this transformation nomic investment based on self-interest. through the promulgation of the idea that «Stability operations are a core U.S. military mission that the The U.S. is uniquely positioned to lead this revolution in [DoD] shall be prepared to conduct and support. They third generation warfare, as its own philosophical roots shall be given priority comparable to combat opera- are based on the belief that, «Governments are instituted tions and be explicitly addressed and integrated across among Men, deriving their just powers from the consent all DoD activities25.» In language that could have been of the governed, – Whenever any Form of Government taken directly from Marshall’s original speech, it stated becomes destructive of these ends, it is the Right of the that, «Stability operations are conducted to help esta- People to alter or to abolish it…» Thus any government blish order that advances U.S. interests and values. The that does not protect «Life, Liberty and pursuit of immediate goal often is to provide the local populace Happiness»23 of its people is unjust and need not be with security, restore essential services, and meet obeyed. By promoting medical stability operations, the humanitarian needs. The long-term goal is to help U.S. military is able to validate the legitimacy of its cause develop indigenous capacity for securing essential ser- as well as accomplish Sun Tzu’s «acme of generalship,» vices, a viable market economy, rule of law, democratic that of winning one’s objectives without going to war24. institutions, and a robust civil society.» So while superior firepower can determine a single battle’s victory, By working with the host nation to provide medical policy generated out of the experiences in Afghanistan VOL. 83/3 care and improve the public health system the U.S. and Iraq recognizes that there can be no lasting peace increases local government validity and relevance in nor any healing of a nation’s wounds without an

International Review of the Armed Forces Medical Service 36 Revue Internationale des Services de Santé des Forces Armées investment in the public health system and medical need to develop constructive alternatives to the tradi- care for the local population. tional «trial by combat» methods for determining the primacy of international policy. In those discussions, For the Military Health System (MHS), which ensures military medical stability operations can offer one the U.S. military remains fit to fight and ensures woun- option to «help the world's weakest states build heal- ded Service members are properly cared for, these thy and educated communities, reduce poverty, deve- changes reflect not only a philosophical return to the lop markets, and generate wealth29.» original justifications for America’s Revolutionary War, but also present significant structural challenges. ABSTRACT Representing 130,00 military medical personnel with an annual budget of $40 billion, the MHS will take Stability operations refer to overseas military missions years, if not decades, to develop the policies, systems, conducted to establish and maintain security and stabi- and funding streams necessary to build a medical sta- lity through the provision of essential services and bility operations capability equal to its Force Health emergency reconstruction. In November 2005, the Protection and Readiness capabilities. But while parity Department of Defense (DoD) issued DoD Directive between the two missions may never be achieved, the 3000.05 which identified stability operations as a core need for change is indisputable. mission that the U.S. military shall be prepared to conduct and support. This article provides a historical Soon after the invasion of Afghanistan the 2002 review of the U.S. military record of past engagement National Security Strategy26 noted that a «world in stability operations through a wide range of activi- where some live in comfort and plenty, while half of ties including humanitarian relief and assistance, the human race lives on less than $2 per day, is neither nation building, and counterinsurgency. It calls for a just nor stable.» Immediately following the invasion systematic review of the lessons learned from the past of Iraq, the 2004 National Commission on Terrorist century of military health support to stability opera- Attacks Upon the United States27 echoed these senti- tions and develops ways to incorporate these lessons to ments, recommending ‘‘A comprehensive U.S. strategy inform and shape policies for future overseas military to counter terrorism should include economic policies medical engagement activities. The article also high- that encourage development, more open societies, lights current efforts within the DoD to institutionalize and opportunities for people to improve the lives of medical stability operations and develop relevant poli- their families and enhance prospects for their chil- cies to support these missions. dren.» The most recent Joint Operating Environment (JOE) report28, published by Joint Forces Command in REFERENCES 2010, identifies six of the eleven trends influencing 11. Department of the Army. Stability Operations (FM3-07). the world’s security: globalization, demographics, cli- Washington DC; 2008. mate change, natural disasters, food, water, and pan- demics, which could be ameliorated by expanding 12. BAKER JB. The Doctrinal Basis for Medical Stability medical stability operations. Operations. Military Medicine. 2010;175:14-20.

In 2008, then-Assistant Secretary of Defense for Health 13. BONVENTRE EV, HICKS KH, OKUTANI SM. U.S. National Security and Global Health: An Analysis of Global Health Affairs, Dr. Ward Casscells created the International Engagement by the U.S. Department of Defense Health Division (IHD) to begin this process. The role of Washington DC: Center for Strategic & International the International Health Division was designed to advise Studies; 2009. the Assistant Secretary of the interaction between the MHS, host nation civilians and their health infrastructure 14. YATES LA. The US Military's Experience in Stability in counter-insurgency, post-conflict reconstruction and Operations, 1789-2005. Kansas: Combat Studies Institute stabilization, and humanitarian assistance and disaster Press; 2006. response operations. The anticipated publication of the 15. ARMSTRONG KK. Army Medical Department Support to first DoD Instruction 6000 on «Military Health Support Stability Operations. Carlisle, PA: U.S. Army War College; for Stability Operations,» which will promulgate the 2007. authorities, roles, and responsibilities of the various service components to transform the MHS marks the formal 16. WILENSKY R. Military Medicine to Win Hearts and Minds beginning of this process. Lubbock: Texas Tech University Press; 2004.

In studying the record of military medical stability ope- 17. United States Marine Corps. Small Wars Manual rations, history reminds us that the «new» efforts to Washington DC: Skyhorse Publishing; 2009. develop medical stability operations capabilities merely 18. SAMS C. Medic. Armonk: M.E. Sharpe; 1998. reflect the original Constitutional goals of forming more perfect Unions, establishing Justice, and promo- 19. CHERNY A. The Candy Bombers. New York: G.P. Putnam's ting the general Welfare- only this time on a global Sons; 2008. scale. But with ever increasing threats and decreasing budgets, one unanswered question remians, «Will 10. Department of the Army. Counterguerrilla Operations (FM 31-16). Washington DC; 1967. VOL. these efforts succeed?» At this point, no one can tell. 83/3 What is clear is that if humanity is to survive, it will 11. Department of the Army. Nation Building Contribution of

International Review of the Armed Forces Medical Service 37 Revue Internationale des Services de Santé des Forces Armées the Army Washington, DC: Deputy Chief of Staff for 21. THOMPSON D. China's Soft Power in Africa: From the Military Operations; 1968. "Beijing Consensus" to Health Diplomacy. China Brief, 2005; 5. http://csis.org/files/media/csis/pubs/051013_china_ 12. ZAJTCHUK JT. Military Medicine in Humanitarian soft_pwr.pdf. Accessed March 2010. Missions. In: Lounsbury DE, Bellamy RF, eds. Military Medical Ethics. Washington DC: Borden Institute; 2003. 22. XIAOHUO C. Largest hospital ship tests its mettle. China Daily; 2009. http://www.chinadaily.com.cn/china/2009- 13. U.S. Department of State. Background Note: Honduras. 03/24/content_7608338.htm. Accessed March 2010. http://www.state.gov/r/pa/ei/bgn/1922.htm. Accessed March 22, 2010. 23. The United States Declaration of Independence. http://www.archives.gov/exhibits/charters/declaration.html. 14. MITCHELL CH. The Medic as an Instrument of National Accessed April 2010.` Policy, Strategy Carlisle, PA: U.S. Army War College; 1991. 24. Winning One's Objectives without Going to War Reference. 15. TARANTINO D. Asian Tsunami Relief: department of Defense Art of War. http://www.chinapage.com/sunzi-e.html. Public Health Response: Policy and Strategic Coordination Accessed April 2010. Considerations. Military Medicine. 2006;171:15-18. 25. U.S. Department of Defense. DoD Directive 3000.05. 16. VANDERWAGEN W. Health Diplomacy: Winning Hearts Washington DC; 2005. and Minds through the Use of Health Interventions. Military Medicine. 2006;171:3-4. 26. The National Security Strategy, 2002. http://georgew- bush.whitehouse.archives.gov/nsc/nss/2002/index.html. 17. BRENNAN R. Humanitarian aid: some political realities. Accessed March 2010. British Medical Journal. 2006;333:817-818.

18. OSPINA HC. Cuba Exports Health Le Monde Diplomatique. 27. The National Commission on Terrorist Attacks Upon the August 2006. http://mondediplo.com/2006/08/11cuba. United States. The 9/11 Commission Report, 2004. Accessed March 2010. http://www.9-11commission.gov/. Accessed March 2010.

19. Cuba Health Forum. Washington, DC: Center for Strategic 28. United States Joint Forces Command. The Joint Operating and International Studies; 2010. Environment (JOE), 2010. http://www.jfcom.mil/newslink/ storyarchive/2010/JOE_2010_o.pdf. Accessed March 2010. 20. Global Security.org. Type 920 Hospital Ship http://www.globalsecurity.org/military/world/china/type- 29. Fight Global Poverty http://change.gov/agenda/foreign_ 920.htm. Accessed March 2010. policy_agenda/. Accessed March 2010.

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VOL. 83/3

International Review of the Armed Forces Medical Service 38 Revue Internationale des Services de Santé des Forces Armées Medical Planning of Chinese Armed Forces in 5·12 Wenchuan Earthquake Rescuing Operations.* ARTICLES ARTICLES ARTICLES ARTICLES

By S. GUO❶, Z. YANG❶, X. WU❶, C. CHEN❶, Y. LI❶ and L. MA❶. P. R. of China

Shusen GUO

Professor and director of Health Teaching and Research Division of Logistics Command Academy of Chinese PLA. Got bachelor degree from the Fourth Military Medical University and master degree from the Second Military Medical University. Have been working at the Aviation Medical Institute of Chinese Air Force and the Health Department of General Logistic Department of Chinese PLA. Performs teaching and research work in military medical service field. Address: No.23, Taiping Road, Haidian District, Beijing 100858 China. E-mail: [email protected]

RÉSUMÉ Organisation médicale des forces armées Chinoises lors des opérations de secours au tremblement de terre du 12 mai 2008 dans le district de Wenchuan. Lors des opérations de secours faisant suite au tremblement de terre du 12 mai 2008 à Wenchuan, la planification médicale des Forces Armées chinoises comprenait l’organisation d’un système médical, la doctrine d’utilisation des moyens médicaux, leur déploiement, l’adaptation des moyens de secours, leur intégration dans l’ensemble des secours médicaux etc… L’organisation des secours médicaux impliquait deux secteurs, l’un étant sous la responsabilité des services médicaux proprement dits, l’autre sous celle du soutien aux services médicaux. Les services médicaux militaires furent divisés en éléments organiques médicaux indépendants et en éléments mobiles, agissant davantage comme des équipes opérationnelles que comme services de soutien des forces. Ces éléments furent déployés et répartis suivant les besoins dans les cinq zones d’intervention. Leur répartition fut ensuite adaptée à l’évolution des étapes de secours. La coopération médicale entre l’Armée Populaire de Libération et la police est organisée avec efficacité.

KEYWORDS: Earthquake, Rescuing, Operational Medical Planning, Wenchuan. MOTS-CLÉS : Tremblement de terre, Secours, Planification des secours, Wenchuan.

On May 12, 2008, a magnitude 8.0 earthquake took ESTABLISHMENT OF MEDICAL RESCUE place in Wenchuan in Sichuan Province of China. The ORGANIZATION SYSTEM health system of Chinese Armed Forces responded quickly and worked hard, to rescue the wounded, to The medical rescue organization system included 2 parts, carry out epidemic prevention, to maintain the health one was the medical service command system, and the of civilian and military people, etc. The medical plan- other was the medical service support system. ning of earthquake rescue is that the medical departments design the main contents and methods of the 1. The Medical Service Command System medical rescue work. In the rescue operations, the Usually the disaster rescue headquarters of China were set medical planning included establishing medical service command and support system, arranging for medical forces, using of the medical forces, deployment of the ❶ Health Teaching and Research medical forces, the changing of medical rescue Division of Logistics Command Academy of Chinese PLA. emphases, and the cooperation of medical rescue * Presented at the 38th World Congress on Military Medicine, VOL. Kuala Lumpur, Malaysia, 4-9 October 2009. work, etc. 83/3

International Review of the Armed Forces Medical Services 39 Revue Internationale des Services de Santé des Forces Armées up at central government. The military command system first level preventive medicine units. The third level health was a part of national disaster rescue command system. protection and epidemic prevention organizations were And the medical service command system was a consti- out of the disaster area, which were mainly supervising, tuent part of the military command system. In instructing and supporting the former two levels. Wenchuan earthquake rescue operations, we set up 4 levels military medical service command organizations. 2.3 Three Levels of Medical Supply and Equipment The first was headquarters of the armed forces. In the System. headquarters there was medical service command orga- The first level was medical supply units in military troops nization and the medical officers from the strategic or contingents which provided organizational support to health department worked in it. The second was theatre military forces and organic medical teams. The second medical service command organization and the medical level was field medical supply and field equipment main- officers from the CHENGDU Military Region mainly taining station in each Duty Area which provided district made up of this level. The third level was duty areas’, support to all medical organizations in the Duty Area. The which was divided into five in main disaster area. The third level was medical supply warehouse out of the disas- fourth was military contingents’ organic medical units. ter area which mainly provided medical materials and equipment to first and second levels. In each medical service command organization, there were four groups. They were integrate planning group, ARRANGEMENT AND DEPLOYMENT medical treatment and evacuation group, health protection and epidemic prevention group, medical supply and OF THE MEDICAL FORCES equipment group. 1. Arrangement of the Medical Forces The headquarters of armed forces joined in each govern- The principle of the medical forces arrangement was: ment disaster rescue headquarters, and made up of the Using the strongest forces first, using the near forces, combined command system. The head of government using the sufficient forces at first, and using the mixed was the commander; the armed forces commander is organizing forces. deputy commander. Using the strongest forces firstly: That was firstly to use 2. Medical Service Support System the emergency medical teams constructed by the nation Disaster medical service system included the medical treat- to and the emergency mobile medical forces constructed ment and evacuation system, health protection and epi- by the armed forces. Using the near forces: That was to demic prevention system, medical supply and equipment use the near medical forces belong to adjoined Military system. Region’s and the Headquarters. Using the sufficient forces in the forepart: That was to prepare and use suffi- 2.1. Three Levels of Medical Treatment and cient medical forces at first. Using the mixed organizing Evacuation System. forces: That was to organize the field medical forces with different kinds of medical personnel, such as medical The earthquake wounded was treated in different levels. treatment, prevention medicine, and psychology person- Level one medical support was First Aid on site. It provi- nel, and medical treatment personnel must include sur- ded emergency resuscitation, stabilization and evacuation gery, internal medicine, gynecology, and dermatology of the wounded to the next level. It was carried out by personnel. forward medical teams and organic medical units. Level two medical supports were provided by field hospitals or mobile hospitals and some base hospitals in the disaster 2. Deployment of the Medical Forces area. It performed limb and life saving surgery operations, Medical deployment must be based on disaster relief mis- wound exploration and debridement, fracture fixation, sions, the order of the military commander, the intention etc. Level three medical support was implemented by rear of the logistics commander, and the terrain conditions. hospitals out of disaster area and it provided the woun- The medical Forces deployments of Wenchuan earth- ded for specialist medical treatment and definitive medi- quake rescue operations adopted the form of area cal care. deployment, and each Duty Area deployed some medical organization. 2.2. Three Levels of the Health Protection and Epidemic Prevention. In the Wenchuan earthquake rescue operations, the mili- In the disaster area, there were two levels of health pro- tary medical institutions deployed in different styles consi- tection and epidemic prevention organizations. The first dering the equipment, terrain, and disaster relief missions. level was troop’s organic preventive medicine units. It was First, medical institutions use the field medical containers basic preventive teams to carry out disease prophylaxis and tentages to make up of the field hospital. The contai- measures in village and small town. The second level was ners field hospital had advanced equipment and informa- field medical preventive teams which were sent by the tion technology, mobility, and self-maintenance ability, campaign and strategy medical organizations such as and effectively solved the shortage of front-line medical Military Region’s CDC and some Military Medical resources and the difficulty of the wounded treatment. VOL. 83/3 University. The field preventive teams were responsible Second, medical institutions were deployed in the front- for Duty Areas preventive medicine and instructed the line of earthquake rescue operations. Where there were

International Review of the Armed Forces Medical Services 40 Revue Internationale des Services de Santé des Forces Armées the wounded, the places were the battlefield, and the personnel who were mainly general surgery. Their main places medical institutions were deployed. Third, the task was at first to split several forward medical teams to mobile medical forces were deployed in the disaster area do first aid on site, and then to set up disaster medical sta- local hospitals. After the earthquake, some medical insti- tion, carrying out emergency treatment for the wounded tutions in the disaster areas were overload and treated and sick. the wounded at the first time. When other military medical institutions arrived at the area they strengthened the Specialist Surgical Teams. The team included 6 ~ 8 special local military hospitals, and treated the earthquake woun- technical personnel, with skilled technology, preferable ded together. Fourth, some were deployed dispersedly, equipment. Their task was to go to the front-line of the carried medical service to villages and houses. Some medi- disaster areas and join into the medical stations or tempo- cal institutions sent out forward medical teams to treat rary hospitals, to carry out specialist surgery. the wounded on site. Epidemic Prevention Teams. The personnel of epidemic THE TYPES AND TASK prevention teams mainly came from the disease prophy- OF THE MEDICAL FORCES laxis and epidemic investigation staff, and sometimes there were experts of epidemiology and hygiene. Each In earthquake rescue operations, the armed forces medi- team had about 30 ~ 50 personnel. They were in charge cal forces were not only to support the military troops of the health guidance and epidemic prevention. They but also directly involved in earthquake relief, to cure the also assisted the military contingents with epidemic sur- wounded, to fight against the epidemic. They were the veillance, elimination the major epidemic, supervision the "fighting teams" rather than the "service team”. Military food and water. medical forces can be divided into the Organic Medical Forces which attached to their military contingents and The Military Medical Experts guide group of Earthquake independence Mobile Medical Forces which were sent Rescue. It consisted of the academicians and senior out by Military Region’s or Headquarters’ hospitals, CDC, experts. It instructed the front-line medical rescue, imple- and medical supply warehouse. mented tele-medicine instructions, and guided the rear hospitals specialist medical treatment of the wounded 1. Organic Medical Forces and sick. Organic Medical Forces are the medical support units which are the part of and commanded by the military THE CONVERSION OF contingents. They are not only supporting their own mili- THE MEDICAL SUPPORT FOCUS tary contingents, but also carrying out first aid, emergency treatment and early treatment for the wounded After the Wenchuan Earthquake happened, getting that come from disaster area. In Wenchuan earthquake along with the disaster rescue, the focus of medical sup- rescue operations, 2,710 health personnel from more than port was changed according the rescue demand. In the 1- a hundred Organic Medical Units went to the disaster 2 days after the earthquakes, the most important task was areas with their military contingents to implement earth- to deploy the medical forces and to carry out front line quake rescue medical service. first-aid. In the 3-8 days, the focus was to save lives and transfer the wounded backwards. In the 9-29 days, the 2. Mobile Medical Forces main work was to prevent the disease and the epidemic. Therefore, the focus of medical support changed through In Wenchuan earthquake rescue operations, more than the four stages. two hundreds medical treatment teams, disease prevention units, psychological rescue teams, and field medical 1. The Stage of Transition from March and equipment maintenance teams coming from the General Deployment to Rescue the Wounded Hospital of People's Liberation Army, the Military Medical University, Academy of Military Medical Sciences, other The medical and prevention medicine rescue teams prepa- military hospital, and CDC, a total of 4351 medical person- red for leaving in the shortest time after received the nel went to the disaster area. order. They rushed to the disaster area day and night by railway, by road, and by air. 2 hours after earthquake, the Mobile Medical Forces are rapid response organizations. first medical team with 24 personnel arrived at serious They have different types and different task. disaster area Dujiangyan. 12 hours after earthquake, 28 medical and prevention medicine rescue teams arrived at Field Hospitals. The field hospital usually had 80~120 per- disaster area. 48 hours after earthquake, 58 medical and sonnel and 80 ~100 beds with the standard medical sup- prevention medicine rescue teams arrived at disaster area. ply and equipments. Their main task was to deploy as 60 hours after earthquake, more than 120 medical and medical stations or temporary hospitals in the disaster prevention medicine rescue teams arrived at disaster area. areas, to carry out primary surgery treatment and some The 72 hour after the earthquake, is the "golden time" to specialist treatment for the wounded to carry out medical rescue the wounded. Arriving of a lot of medical forces support to the earthquake rescue forces, and to accept was crucial for the wounded rescue. In order to rescue the the wounded evacuated from front-line medical station. wounded, the medical force first deployed medical work VOL. units, and then dispatched the medical teams to search 83/3 Disaster Rescue Medical Teams. Each team had 30 ~ 40 and rescue the wounded, and lastly set up the camp living

International Review of the Armed Forces Medical Service 41 Revue Internationale des Services de Santé des Forces Armées facilities. In the shortest time, the medical units completed MEDICAL COOPERATION the transition from deployment to rescue the wounded. Medical cooperation corresponded with collaboration 2. The Stage of Transition from Emergency rescue to activities among medical units or between medical units System Professional Treatment and other rescue forces. After Wenchuan earthquake the national government sent various types rescue forces Along with the searching and rescue work extending, into the disaster areas. Medical forces would work with mass the wounded from disaster areas arrived at medical engineering and fire fighting forces, transportation and units. The medical units need to treat a lot of the woun- communication forces. They should cooperate very well ded, and their workload suddenly increased. At the time, in order to save the lives of the wounded as much as pos- the medical work should focus on the system treatment of sible. There were both health department of armed the wounded. On the one hand, the system of the woun- forces and local health department, and they need work ded evacuation must be established quickly. According to together and cooperation. There were hundreds of the ability of medical units, the important work was to medical units, the Organic Medical Forces and Mobile quicken the wounded transfer rate and improve hospital Medical Forces, the medical treatment teams and epide- bed velocity. On the other hand, we should pay more mic prevention teams, and they need cooperate very attention to the implementation of medical treatment well. Medical cooperation was very important in the and security regulations. The medical units must strictly earthquake rescue operations. establish and implement medical treatment regulations of wartime, make reasonable adjustments of personnel First, organizing the medical cooperation between the and groups, deploy the wards scientifically, implement PLA and Armed police, and the militias. In earthquake the responsibility and management rules strictly. The rescue, military troops, armed police and militia worked medical units must also insist on collective consultation of together. The militia forces hadn’t health personnel, and the severe wounded, the first consulting doctor’s respon- they need the medical service support of armed forces. sibility, and supervising all aspects of medical treatment The PLA and Armed police both had their own medical quality. service system, and they need cooperation with each other. Second, organizing the cooperation between the 3. The Stage of Transition from Medical Treatment Organic Medical Forces and Mobile Medical Forces. The to Prevention Medicine two kinds medical forces each had their own task but 10 days after the earthquakes, the majority of the woun- their work were linked together by the wounded treat- ded had been properly treated and evacuated, but as the ment. So we should confirm the treatment capability of dirty circumstances, epidemic prevention work became the two kinds medical forces and the wounded evacua- the top priority. In order to ensure no major epidemic tion relationship between them, and make their work after the disaster, the focus was timely transferred from can be linked and cooperated. Third, organizing the medical treatment to medical epidemic prevention. First, cooperation among the Duty Areas. In Wenchuan earth- we trained some medical treatment personnel to do epi- quake rescue operations, the disaster area was divided demic prevention work. Second, we arranged and into five Duty Areas. Each Duty Area was deployed some deployed the epidemic prevention personnel unified, and earthquake rescue forces and medical forces. Therefore, ensured every town having at least two professional pre- there was a lot of medical cooperation among the Duty vention personnel and each village having one trained Areas to ensure the wounded rescue and epidemic pre- prevention personnel. Third, we must deal with the body vention smoothly and effectively. of the victims and animal remains properly. Fourth, we should pay more attention to the key places for preven- SUMMARY tion measures, such as large-scale garbage dumps, animal In 5·12 Wenchuan Earthquake rescue operations, the breeding farms, people resettlement places, the tent medical planning of Chinese Armed Forces included schools, etc. establishing medical service system, arranging for medi- 4. The Stage of Transition from the Civilian to both cal forces, using of the medical forces, deployment of the medical forces, the changing of medical rescue Civilian and Military Personnel emphases, and the cooperation of medical rescue work, As the weather changed, the rain was coming, and the etc. The medical rescue organization system included 2 disaster area might enter the epidemic period of infec- parts, one was the medical service command system, tious diseases. The disaster rescue forces overloaded work and the other was the medical service support system. with long-terms. Their physical consumption increased, Military medical forces were divided into the Organic and there was a greater risk of epidemic diseases. Along Medical Forces and independant Mobile Medical Forces, with the rescue job changed to the reconstruction of the they acted as "fighting teams" rather than the "service disaster area, the military medical forces support’s team”. There were 5 mission areas, in each area suffi- emphases was diseases prevention of military troops as cient medical forces were deployed. The medical rescue well as the medical treatment and epidemic prevention emphases were changed according to the rescuing ope- work of civilians. The medical forces sent the forward rational stages. And medical cooperation, between the medical teams to military troops and carried out medical PLA and Armed police, among the Duty Areas, was VOL. service along with the troops. organized effectively. 83/3

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International Review of the Armed Forces Medical Service 43 Revue Internationale des Services de Santé des Forces Armées Health Risks Assessment in Operations A French Focus. ARTICLES ARTICLES ARTICLES ARTICLES

By V. DENUX and N. GRANGER-VEYRON. France

Valérie DENUX

Lt Col Valérie DENUX was graduated, and earned her Medical Doctorate from the University of Bordeaux in 1995. In addition, she holds different aca- demic diplomas and post graduate courses: catastrophic medicine and tropical diseases (1995), Master of Management (2000), International Relations Certificate (2007), Logistic Degree (2nd level) (2008), Master of Strategy (2009). She attended the Joint Staff College Course in Paris (2008-2009).

From 1996 to 2004, she served as General Practitioner in units (most of time in the Army but on Air Force Base and on board too) and acquired a strong operational experience (Balkans, French Polynesia, Lebanon, Djibouti and Chad). From 2005 to 2008, she served as a Medical Staff Officer in the French Joint Surgeon’s General Staff and was involved in the Military Health Organization, in the Medical Information and Communication System and in French and international medical concepts & doctrines (NATO, EU).

RÉSUMÉ Evaluation des risques sanitaires en opérations : le point de vue français. La protection de la force devient une des préoccupations les plus importantes des chefs militaires. La communauté médicale militaire a un rôle important à jouer afin d’atteindre un niveau de protection suffisant pour les troupes. Pour cela, l’évaluation du risque sanitaire de la zone d’intérêt est essentielle afin de développer les meilleures mesures préventives possible. Plusieurs nations et organisations ont développé le concept de « renseignement à caractère médical » afin d’assurer une évaluation effi- cace des risques et des menaces sanitaires. La France a mis en place une organisation originale et spécifique ou la communauté médicale et celle du renseignement ne se mélangent pas, afin de ne pas créer de confusion dans leur activité respective, mais sont capables de joindre leurs efforts sur demande du commandement.

KEYWORDS: Force Health protection, Health Risks Assessment, Medical Intelligence, French system. MOTS-CLÉS : Protection santé de la force, Evaluation des risques sanitaires, Renseignement à caractère médical, Système français.

INTRODUCTION the chemical, biological, radiological and nuclear domains (CBRN)) new requirements have to be faced. Today, Armed forces, like society, cannot escape pre- The military health services have a crucial role to play in caution and prevention requirements, both at collec- the expertise and decision-making process. Particularly tive and individual level. Thus, the health risks and they have to provide preventive actions and adequate threats assessment in operations is essential to ensure countermeasures. the required force health protection level. The command has to prevent and also to maintain the operatio- This new attitude towards health risks and new threats nal capability of deployed forces, which may be com- emergence, including CBRN, emerge out of the promised by a degraded environment, either through «Medical Intelligence» (MEDINT) concept, developed with a natural or an induced agent. In theatre, interac- initially by the United States and then by the North tions between human and his environment need quali- Atlantic Treaty Organisation (NATO) in its transforma- fications. Epidemiology alone is insufficient to assess tion process. Todays, all the military health services VOL. the risks to the forces. In order to obtain sufficient around the world agree with the idea that irreversible 83/3 information, surveillance and analysis regarding health health risk assessment is an essential tool of operatio- risks and the emergence of new threats (in particular in nal command support. In the current strategic context,

International Review of the Armed Forces Medical Services 44 Revue Internationale des Services de Santé des Forces Armées health risk assessment data is an integral part of the THE DEFINITIONS decision-making process at all levels. The following definitions have been developed: However, the nations, which have the same objective • The Health risk assessment (HRA): In a theatre, the of force protection, have however various approaches force can operate within an environment characterised to provide the MEDINT. Some are providing it throu- by a threatening environmental situation. This context ghout the intelligence cycle, others are elaborating it can affect the force’s health, which may be detrimental within the medical branch and some nations such as to its operational capacity. In these conditions, marked France separate the work in two parts not to confuse by uncertainty, the command must determine for all the medical and the intelligence functions. The goal of operation phases the acceptable risk level for the force the French medical community is to protect its medical and its environment. In this respect, a health risk ethic by not playing active role in the intelligence. The assessment is required to measure the impact of these French Joint Military Medical Service (Service de santé risks and protect the force, notably in terms of health des armées - SSA) in collaboration with the operational and safety in operations. Primarily, this assessment staff conducts the Health risk assessment (HRA) and involves the medical, epidemiological and environmen- the intelligence department, which has specific techni- tal domains. The health risk assessment is notably esta- cal skills for the integration of data outside the scope blished based on medical information2. of medical competence, produces the Intelligence for the medical aspects (IMA). The latter has to be required • Intelligence for the medical aspects (IMA): This is by the operational staff if needed to complete the the result of the research carried out by the joint intel- medical analysis. Thus, the Health risk assessment com- ligence function for the health risk assessment and for pleted if necessary by the Intelligence for the medical the determination of the health aspect of a potential aspects is in line with the MEDINT. threat.

THE FRENCH SYSTEM GENESIS THE PROCESS The French Joint Military Medical Service has expertise The French Joint Military Medical Service, within the in epidemiological surveillance, gained from the colo- medical community as a whole, provides the armed nial era and exploited through its network such as the forces with the medical information which it collects epidemiology and public health departments and the openly. Its sources include its field personnel (who can- Tropical Diseases Institute (IMTSSA). not be requested to search for classified information or use their status to forcibly extract information or break However, to meet the challenges of changing operatio- individual medical confidentiality), its hospitals, nal needs, the system of classical epidemiological infor- research centres and institutes, «business» networks mation was no longer sufficient. Today medical deci- (public health, foreign countries) as well as epidemio- sions are a dimensioning aspect in the conduct of ope- logy and public health departments, real-time epide- rations, putting the Health Services at the heart of the miological surveillance systems, preparation centre for «restoration and maintenance of operational capabi- external operations, in charge of analysing the lessons lity». In this context, the Joint Military Staff has increa- learned, and finally all its experts from the health sector. sed the importance of health issues in operational. assessment A «prevention, safety and environment» This medical information is subsequently subject to section has been established in 2003, a doctrine docu- technical analysis carried out by medical experts. The ment relating to hygiene and safety of military opera- joint staff, through the CARBC, carries out the operations has been written and a cell has been created tional analysis of the situation. This product is summa- (Decision Support in radiological, biological and chemi- rized in data sheets and putting on line through mili- cal cell – CARBC), responsible for gathering information tary databases which are available to the command, and analysis in order to provide strategic or operational medical community and intelligence agencies accor- level decision support. The French Joint Military ding to the requests. In order to enhance these data- Medical Service is integrated in these structures for bases, exchanges must be encouraged, in the case of which it trains available experts, it has also developed non confidential information, with the databases of innovative concepts such as space surveillance system in the international organisations (primarily the UN, real time outbreak of the armed forces and its software NATO3 and EU4). ASTER1, and or health monitoring system. The French Department of Defence has effective tools for the ana- Thus, the health risk assessment produced can be used lysis of the health scenario. They are shared by the joint in operations, exploited at strategic, operational and military staff and the French Joint Military Medical 2 Medical information includes all health data accessible and publishable by health Service. At last, a Joint Forces concept of Health Risk professionals, in compliance with the medical confidentiality rules. Assessment has been developed in 2008 in order to In the Joint Military Medical Service, medical information is notably formalised based on the concept of surveillance, watch and epidemiological survey. The collec- define the framework and the reference points, which tion of medical information is a technical activity justifying specific clinical qualifi- improve the contribution of the different organisations cations (epidemiology, community medicine, public health, preventive medicine, clinical toxicology, veterinary medicine etc.). involved. 3 UN: United Nations. VOL. 83/3 1 ASTER: Alerte et Surveillance en TEmps Réel (Alert and Surveillance in Real Time). 4 EU: European Union.

International Review of the Armed Forces Medical Services 45 Revue Internationale des Services de Santé des Forces Armées tactical levels and during all deployment phases of the of anticipated planning work already integrated into a troops in the field. It is complemented and updated health risk assessment, based on the information provi- throughout the operation. Before the deployment, this ded by the joint intelligence function, and based on product is used for the planning, during the deploy- the field information provided by the liaison and field ment and the engagement, it enables the Force reconnaissance team, into which medical personnel Commander to define the general hygiene and safety may be integrated. in operations policy of the theatre (specific directive), and enables the Medical advisor (MEDAD) to partici- During the different planning phases or the control of pate in the adaptation of the health support system. operations, additional assessment requests can be Finally during the disengagement, the implementation made by the French Joint Military Medical Service for of the lessons learned analysis process can be improved. the collection of open medical information or technical analysis and by the staff to complete the risk assessment with operational data. Figure 1: Health risk assessment process. CONCLUSION Joint Validated The current risks must be systematically assessed with intelligence function medical information the objective to preserve the health of the operational DCSSA DRM/others personnel. This will protect the interests of individuals IMTSSA Health risk and guarantee mission success. These risks correspond assessment to the provoked and natural biological environment, CARBC’s technical the industrial or technological environment and the and decision-making risks inherent in the health and safety of working units Health chain conditions. The HRA must therefore be based on a request pragmatic and systematic approach. This will have to include for each mission the monitoring of accessible Operational databases, the integration of the operational require- use of the HRA ment, the identification of emerging risks, the analysis EMA and processing of the information collected and the COMFOR creation of maps. This systematic approach is completed, depending on the context, in close collaboration with the joint intelligence function, notably with THE PURPOSES regard to the identification of threats. With this The scope of the health risk assessment is the protec- approach, the French ministry of defence realizes a sys- tion of armed forces against health risks. The force can tematic health risks and threat assessment in order to operate in an environment which may have an impact ensure the best force protection possible. Some of its on its health and it could jeopardize its operational departments, such as the medical, the operational and capabilities. With this uncertainty, the commander the intelligence departments are involved in this pro- must determine, at all phases of the operation, the cess each according to its own specific skills. level of risk acceptable to the force and its environment. For this, a health risk assessment is necessary to ABSTRACT measure impacts and to ensure force protection, parti- Force Health protection becomes one of the most cularly in terms of hygiene and safety in operations. For important preoccupation of the military commanders. that, it provides operation and force command with The Military Medical Community has an important role elements as health and safety in operations, determi- to play in order to achieve a sufficient level of troops nation of situational and preventive measures during protection. For that, a health risk assessment of the force engagement, recommendations associated with operational area of interest is essential to provide the the medical counter-measures to be implemented, in best preventive measures possible. Many nations and particular in the CBRN domain, and assessment of organizations developed the concept of Medical medical resources and infrastructures in the area of Intelligence to ensure an efficient assessment of the operational interest. The intelligence for the medical health risks and threats. France implemented a specific aspects might complete this analysis with research acti- and original organization in which the medical commu- vities conducted by the joint intelligence to determine nity and intelligence community are not mixed, in the health aspect of a possible threat. order not to confuse their activities, but able to join their efforts if required by the commander. The health risk assessment must be taken into account in the planning and control of operations. The resul- REFERENCES ting recommendations support operation plans and orders. To guarantee force protection, the health risk 11. PIA- 04.101 N°179/DEF/CICDE/NP du 09 juillet 2008. assessment must be integrated into the planning of 12. Lynn McNAMEE. Military Medical Technologie, AFMIC, operations as early as possible. To do this, an initial VOL. 2008. assessment is required based on the medical informa- 83/3 tion provided by the health chain, based on the results 13. OTAN- AJP4.10(A) relative à la doctrine du soutien médical.

International Review of the Armed Forces Medical Service 46 Revue Internationale des Services de Santé des Forces Armées 14. OTAN-AMedP3 relative au « Medical intelligence ». 19. JJ. KOWALSKI, R. WEY, F. DELORME. Renseignement d’in- térêt sanitaire opérationnel, Médecine et Armées, 1998, 15. J-B. MEYNARD, G. TEXIER, SBAI IDRISSI, L. OLLIVIER, R. 26, 1. MICHEL, M. GAUDRY, C. ROGIER, R. MIGLIANI, A. SPIEGEL, J-P. BOUTIN. Surveillance épidémologique en temps réel 10. J-P. BOUTIN, O. RIBIÈRE, H. VAN CUYCK, D. MALOSSE. pour les armées, Médecine et Armées, 2004, 32, 4. Pour une veille sanitaire de défense, Médecine et Armées, 2004, 32, 4. 16. OTAN-Stanag 2235 relatif à l’évaluation avant et après un déplacement. 11. A. JOUAN. Le concept de renseignement médical est-il valide? Comment le définir? Médecine et Armées, 2004, 17. OTAN- Stanag 2481 relatif à la récupération et à la forma- 32, 5. lisation des informations médicales. . 12. E. DARRÉ, H VAN CUYCK, G. CRÉANGE, Planification 18. Conventions de Genève du 12 août 1949 et ses protocoles médicale opérationnelle, les nouveaux acteurs, Médecine additionnels de 1977 et 2005. et Armées, 2005, 33, 1.

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International Review of the Armed Forces Medical Service 47 Revue Internationale des Services de Santé des Forces Armées Monitoring Performance Changes with On-Board Data Recording System.* ARTICLES ARTICLES ARTICLES ARTICLES

By A. GRÓSZ❶ ❷, J. HORNYIK❷, E. TÓTH❷ and A. SZATMÁRI❷. Hungary

Habil Andor GRÓSZ

Brig. Gen. Andor GRÓSZ, M.D., Ph.D., CAS, MC Date of birth: 23. 12. 1951. POSITIONS 2007- Military Deputy Director, State Health Center, Ministry of Defence, Budapest. 2005-2007: Director General, Aeromedical Hospital, HDF, Kecskemét. 1997-2005: Head Physician, Dept. of Aeromedical Research, Aeromedical Hospital, HDF. 2000- Head of Dept., Dept. of Aviation and Space Medicine, Faculty of Medicine, University of Szeged. 1997- Chief Air Surgeon, HDF. 1986-1997: Head Ophtalmologist, Department of Aeromedical Research, Aeromedical Hospital, HDF. SPECIALTIES 2008: Occupational medicine. 1998: Habilitation at Zrínyi Miklós National Defence University. Title: « Issues in aerial transportation of patients and the injured in military medical care »; Budapest. 1991: Ph.D. degree. Title of thesis: « Experiences in measuring the visual work capability of military aircrews ». 1989: Aviation and space medicine. 1985: Ophthalmology. MEMBERSHIP IN BODIES AND ASSOCIATIONS 2009: President of Hungarian Association of Aviation and Space Medicine. 2005- Corresponding member of International Academy of Astronautics. 2003- Elected member of International Academy of Aviation and Space Medicine. 2002- Associate fellow of Aerospace Medical Association (U.S.).

RÉSUMÉ Apport à l’évaluation des performances grâce à un système d’enregistrement embarqué. Le stress psychophysiologique est une caractéristique importante dans le milieu aérien, qui modifie en permanence les performances cognitives des pilotes. Son étude requiert aussi la surveillance continue de l’association événements physiologiques / phé- nomènes. Nous avons étudié en tant que variable objective la fréquence du rythme cardiaque chez 28 sujets, grâce à un système embarqué d’enregistrement des données, conçu par notre équipe. Les sujets ont subi le test de coordination des deux mains de Schuhfried en ambiance de laboratoire. Les variations du rythme cardiaque ont été calculées à partir des enregistrements d’ECG et de l’intervalle RR. Les valeurs du questionnaire TLX de la NASA ont été utilisées en tant que variable subjective pour évaluer les résultats. Notre indice de variabilité de la fréquence cardiaque a décru au cours des activités de travail nécessitant des efforts mentaux. En utilisant d’autres tests psychologiques de niveaux de difficulté différents, la tolérance au stress et, en partie, la condition psychologique individuelle au vol, peuvent être déterminées à partir des modifications de ce paramètre.

KEYWORDS: Cognitive performance, Psychic load, Heart rate variability, On-board data recording system. MOTS-CLÉS : Performance cognitive, Charge psychique, Variabilité de la fréquence cardiaque, Système embarqué d’enregistrement des données.

INTRODUCTION decision, and control, while other support-type activities can more and more be automated. Now the assess- In our days, the fast-growing performance of compu- ment of the so-called «operator status» is in focus which ters allows a certain separation of the man-machine sys- means the physiological, mental, and actual health state VOL. tem in flight in the sense that humans more and more of the individual (the operator) who controls the system 83/3 has to deal with tasks that require human participation, and, at the same time, is a part of it.

International Review of the Armed Forces Medical Services 48 Revue Internationale des Services de Santé des Forces Armées ASSESSING PSYCHIC LOADS IN PILOTS Figure 1: Screen display and keyboard of the Two-Hand Coordination (Tracking) test. The analysis of the data obtained under real work conditions in real-flight situations may largely contribute to the improvement of training methods and flight procedures, and, indirectly, to the reduction of imminent risks in this work activity. Such analyses obviously require data which are sensitive to the changes in cognitive loads. The compilation of such indices is based on the principle that flight as a work activity requires the pilot to coordinate several different cognitive processes1, 2.

HISTORY OF REAL-TIME RECORDING OF PSYCHOPHYSIOLOGICAL DATA DURING FLIGHTS IN HUNGARY The first Hungarian-developed portable device (Balaton Psychocalculator) suitable to detect the actual in-flight psychic state was tested during the spaceflight of Bertalan Farkas, the first Hungarian astronaut. This

microprocessor-controlled instrument, which had a size

of a pocket calculator, included an integrated pulse- ➡ ➡ taking system and a galvanic skin resistance measure- ➡ ment system, and was designed to automatically perform psychological tests and measure physiological ➡ parameters. The performance during the test tasks was controlled by a programmable central unit. Learning before testing, administering the stimuli in the course ters (ECG [2-channel, 5-lead], galvanic skin resistance, of testing, as well as reading the computed values took body temperature, pulse and respiration rates) in a place through its 4-digit numerical display. digital form on a removable cassette. The ground- based subsystem was designed to store and display 4 APPLIED METHODS AND DEVICES recorded data simultaneously . Objective Visuomotor coordination test (Fig. 1) The objective was to verify that heart rate variability During the test session, the spatially and temporally can be used as an appropriate index in the assessment coordinated activity, which is adjusted according to the of psychic loads. actual situation, takes place through the parallel and complex feedback mechanisms of the individuals’ sen- Study Subjects sory and motor functions3. It is basically different from simple reflex processes, also in that there is always a The study included 28 male pilots, who were medically cognitive component in the background of sensory and psychologically healthy, fit to fly, and had a mean motor performances. This device was selected as a age of 30.1±7.91 years. resource of provocation on the basis of these assumable cognitive components, and the several-year experience ❶ Brig. Gen. Habil. Andor Grósz, M.D., Ph.D with this test. State Health Centre, Ministry of Defence 44, Róbert Károly krt., H-1134 Budapest, Hungary. The test assesses the subjects’ accuracy, speed, and level ❷ Maj. József Hornyik of coordination during task-solving. In the task, the Institute For Aviation Medicine, Military Fitness and Research, subject has to guide a round spot along a predetermi- Kecskemét, Hungarian Defence Forces 17, Balaton utca, ned track, using the right hand to move the spot in the H-6000 Kecskemét, Hungary. vertical direction, and the left hand to move the spot in ❷ Erika Tóth the horizontal direction. The track consists of three sec- Institute For Aviation Medicine, Military Fitness and Research, tions, representing the levels of increasing difficulty. Kecskemét, Hungarian Defence Forces 17, Balaton utca, The factory default includes ten measured rounds after H-6000 Kecskemét, Hungary. two rounds of practice. ❷ Lt. Ákos Szatmár Institute For Aviation Medicine, Military Fitness and Research, Kecskemét, Hungarian Defence Forces On-board data recording system 17, Balaton utca, H-6000 Kecskemét, Hungary. The on-board subsystem synchronously records and VOL. stores the relevant flight data (altitude, speed, cockpit * Presented at the 38th World Congress on Military Medicine, Kuala Lumpur, Malaysia, 4-9 October 2009. 83/3 pressure etc.) and several psychophysiological parame-

International Review of the Armed Forces Medical Services 49 Revue Internationale des Services de Santé des Forces Armées Execution of the study Figure 3: The distribution of speed and accuracy values (expressed in T points) achieved in the initial sample The phases of the study are shown in Figure 2. The of the visuomotor coordination test. horizontal axis represents time (in seconds). Meanings of the indicated points: 80 1. 3 minutes in rest – with eyes closed, in comfortable posture, in a darkened room. 70 2. Practice – without measurements. (Description: the track to be followed only appears when the study person moves the spot to the start sec- 60 tion of the track («A»). Then he is instructed to move the spot with his left and right hands in the horizontal 50 and vertical directions, respectively (2/a), then diago- 20 30 40 50 60 70 80 nally (2/b), and then along an arc (2/c), and finally back to the start section. There (2/d) the subject receives the 40 necessary instructions.) 3. Practice (2 consecutive rounds) along the track – without measurements. 30 4. Performing the task (no stops, 10 consecutive rounds) – speed and accuracy are measured. 20 5. 3 minutes in rest – completion of subjective (NASA TLX workload and frustration) scales relating to Figure 4: Changes of the relevant absolute-value psychic load. component of HRV in the rest-load-rest phases according to the study method. Figure 2: The changes in the relevant spectral component of HRV within the study period. 3,5 3 2,5 2 1,5 1 0,5 0 RESULTS Relax 1 Psychic load Relax 2 The study subjects performed the test within 9.17±1.98 Figure 5: HRV increase/decrease data broken down minutes on average (min. 6, max. 13 minutes). The to each study person. mean value of the coordination factor computed by (Comments: The difference between Resting Phase 1 the test was 2.24±0.7. The value of the speed of work and Load Phase is shown on the horizontal axis, while (mean duration) – expressed in T point – is 56.14± 9.92, the difference between Load Phase and Resting Phase 2 and the value of accuracy (mean percent error dura- is shown on the vertical axis. We are interested in the data tion) was 58.46±10.23. of persons who produced extreme HRV reactions falling outside the ±1 standard deviation range). Fig. 3 illustrates the distribution of the speed and accuracy values achieved during the visuomotor coordina- 26 03 24 tion test in the initial sample. 28 25 18 09 27 21 22 11 We used the spectral method for the analysis of heart 19 02 14 rate variability, using exclusively the absolute values 07 measured in the medium frequency range (0.04-0.15 Hz). 10 The detailed test results are summarized in Figs. 4, 5. 28 23 01 Fig. 6. compares the values found on the subjective scales related to workload and frustration, assigned to 2 03 26 the individuals. 02 24 25 19 28 03 18 07 11 14 21 22 27 -3,5 -3 -2,5 -2 -1,5 -1 -0,5 0 0,5 1 1,5 DISCUSSION 01 17 Using the two-hand coordination tracking test and the -2 on-board data recording system, an in-depth analy- VOL. sis of the changes of the following parameters was y=1,6185x-0,3011 83/3 carried out:

International Review of the Armed Forces Medical Service 50 Revue Internationale des Services de Santé des Forces Armées PCT-Anzeige-210x297_V2_A4 07.09.10 12:45 Seite 1 . d e v r e s e r

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Moving science forward Figure 6: Comparison of the values found on Figure 7: Changes of spectral components during load. the subjective scales, assigned to the individuals. (Comments: We are interested in the data of persons who In rest Under psychic load gave extremely subjective opinions falling outside the ±1 standard deviation range). 80 LF 1 difficult but reassuring difficult and annoying 2

LF HF vsz 23 HF 70

vsz 25 vsz 19 60

vsz 02 vsz 09 LF LF 50 frustration vsz 01 work hard vsz 11 HF 20 30 40 60 70 80 HF vsz 14 vsz 20 vsz 18 vsz 27 vsz 24 vsz 07 40

vsz 28 vsz 17 2. Subjective scales for psychic loads 30 The applied NASA TLX (Task Load Index) is a multidi- mensional scaling procedure. It includes six scales, namely: judgement of the load on the basis of (1) men- easy and reassuring easy but annoying 3 4 20 tal and (2) physical requirements, (3) time constraint requirements, the assessment of (4) the individuals’ 1. Spectral analysis of heart rate variability own performance, the levels of the (5) efforts made, 11 From the anatomical and functional points of view, our and the (6) frustration experienced . vegetative functions can be divided into two subsys- tems, namely, the sympathetic system, which controls Reporting the increased difficulty of the situation and emergency situations, and the parasympathetic system, high-level frustration are interpreted as sensitizer-type which controls rest and regeneration. If we are able to responses, while the opposite case (calm, easy, no frus- 12 concurrently follow the effects of these two activities in tration) is seen as a repressor response . a parallel way, then we will have a method which can be used to monitor the sympathetic vs. parasympathetic CONCLUSION 5, 6 balance . The different physiological events, sympa- According to our results, the person who is the fittest thetic or parasympathetic effects add different rhythms for the given task – i.e. the one who performed the (frequencies) as «overtones» to the basic function of the task (which he judged easy and reassuring) quickly and heart. During recording heart rate as physiological data, accurately, with no particular mental efforts – can be such added frequencies appear as peaks on the recor- selected on the basis of the these objective tests and a 7, 8, 9 ded and displayable spectrum . When the ECG is dis- set of subjective responses (Fig. 8). played, the most easily identifiable section is the QRS complex, in which the R-wave is the most visible part. SUMMARY Due to its algorithmic simplicity, most programmes (especially those using automated detection) are set to An important character of the aviation environment is find this peak point when identifying subsequent single psychophysiological stress which always changes the heartbeats and determine the time that have elapsed pilots’ cognitive performance. Its analysis also requires between them. Accordingly, the measured sections are the monitoring of the parallel physiological mentioned as RR distances. The spectral components events/phenomena. As an objective variable, we moni- offered for use are demonstrated in Fig. 7. tored the changes in the medium frequency range of heart rate variability in 28 subjects with an on-board Behind the recorded ECG, there is a continuous value data recording system developed by our team. The sub- which always changes in time and is due to polariza- jects were tested with Schuhfried’s two hand coordination-depolarization, informing us about the contrac- tion test in a laboratory environment. Heart rate variations of the heart. During digital data recording, the bility was calculated from the recorded ECG and the actual degree of the given value is recorded, dividing RR-distances. As a subjective variable, the values of the elapsing time into constant sections (having a look NASA’s TLX questionnaire were used to evaluate the at the process from time to time). According to the results. Our heart rate variability index significantly standard recommendation, optimal data sampling fre- decreased during work activities with mental efforts. quency should fall between 250 Hz and 500 Hz. (The By using further psychological tests with different difficulty levels, stress tolerance and, partially, the indivi- VOL. generally used 200-Hz sampling frequency of the diag- 83/3 nostic devices used in clinical practice may result in data dual’s psychological fitness for flight can be determined loss)10. from the changes of this parameter.

International Review of the Armed Forces Medical Service 52 Revue Internationale des Services de Santé des Forces Armées Figure 8: Who is the fittest person for the given task?

80 1 difficult but reassuring difficult and annoying 2 subjective vszworkload 23 70 reaction NASA TLX vsz 25 vsz 19 60

vsz 02 vsz 09

50 frustration vsz 01 hard work vsz 11 20 30 40 60 70 80 vsz 14 vsz 20 vsz 18 vsz 27 vsz 24 vsz 07 40

vsz 28 vsz 17 speed HRV 30 vs. 80 26 03 24 4 easy and reassuring easy but 28 20 accuracy 25 18 09 27 21 22 11 70 19 02 14

10 07 60 28 23 01 subject 17 50 2 20 30 40 50 60 70 80 03 26 02 24 25 19 28 03 18 07 11 40 14 21 22 27 -3,5 -3 -2,5 -2 -1,5 -1 -0,5 0 0,5 1 1,5 01 17 30 objective -2 y=1,6185x-0,3011 objective 20 measurement measurement selection

REFERENCES H1273-H1280.

1. WILSON, G.F. (2001): An Analysis of Mental Workload in 7. SAYERS BM. (1973): Analysis of heart rate variability. Pilots During Flight Using Multiple Psychophysiological Ergonomics. 16, 17-32. Measures. IJAP 12(1), 3-18. 8. LUCZAK H, LAURING WJ. (1973): An analysis of heart rate 2. WILSON, G.F. (2002): Heart Rate Measures of Flight Test variability. Ergonomics. 16, 85-97. and Evaluation. The International Journal of Aviation Psychology 12(1), 63-77. 9. AKSELROD S, et al. (1981): Power spectrum analysis of heart rate fluctuation: a quantitative probe of beat to 3. FITTS, P.M. The information capacity of the human motor beat cardiovascular control. Science. 213, 220-222. system in controlling the amplitude of movement. J Exp Psychol 1954;47:381-391. 10. IZSÓ L., LÁNG E. (2000): Heart period variability as mental effort monitor in Human Computer Interaction. Behavior 4. GRÓSZ A., SZABÓ S., VÍGH Z. (2005). Adatfeldolgozó & Information Technology 19(4), 297-306. rendszer a légijárművezetők fiziológiai állapotának vizs- gálatára. Haditechnika 1, 2-6. 11. HUEY, B. M., C. D. WICKENS (1993): Workload Transition: Implications for Individual and Team Performance. 5. BOOTSMAN et al. (1994): Heart rate and heart rate varia- National Research Council, ISBN: 0-309-54422-X. bility as indexes of sympathovagal balance. Am. J. Physiol. 266 (Heart Circ. Physiol. 35), H1565-H1571. 12. SCHACHTER, S., & LATANE, B. Crime, cognition, and the autonomic nervous system. In D. Levine (Ed.), Nebraska 6. GOLDBERGER (1999): Sympathovagal balance: how Symposium on Motivation (Vol. 12). Lincoln: University of should we measure it? Am J Physiol Heart Circ Physiol 276, Nebraska Press, 1964.

VOL. 83/3

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Par D. BACHA. Algérie

Djaffar BACHA

Professeur Djaffar BACHA, Chef de l’Unité des Maladies Infectieuses à l’Hôpital Central de l’Armée à Alger (Algérie).

SUMMARY Scorpion Stings: Attitude of the Algerians Military Medical Services. Scorpion stings are a real public Health problem in Algeria-thousands of cases of stings, dozens of fatal cases occur every year. Military population is concerned by this problem mainly troops which are exposed to the risk of contact with scorpions about 300 cases are recorded every year.

Consequently, military Health services took appropriates measures to protect soldiers from scorpion stings and to treat those whom are victims.

MOTS-CLÉS : Scorpion, Piqûre, Militaire, Prévention, Traitement. KEYWORDS: Scorpion, Sting, Military, Prevention, Treatment.

INTRODUCTION Nous proposons donc, de tenter d’apporter quelques éclairages sur la question à la lumière de l’expérience Le choix de cet article portant sur l’envenimation scor- des Services de Santé Militaire Algériens qui date de pionique trouve à nos yeux plus d’une raison d’être : vingt ans maintenant.

- La première est que l’envenimation scorpionique est En Algérie, les données épidémiologiques relèvent considérée maintenant comme un problème de santé quelques 50.000 piqûres/an avec une mortalité d’envi- publique tant par sa morbidité que par sa mortalité. De ron 100 Décès/an. nombreux pays sont concernés USA, Mexique, Inde, Arabie Saoudite, Maroc, Algérie… En milieu Militaire : une moyenne de 300 piqûres de scorpion sont enregistrées chaque année. - La seconde est liée à une lacune du programme de l’enseignement médical où ne figure pas, ou très peu, Les chiffres étaient doubles avant la mise en place d’un les problèmes de l’envenimation scorpionique ou vipé- programme d’action amorcé en 1987 et basé à la fois rine. C’est donc à la formation continue qu’échoit le sur la prévention par la sensibilisation et l’information rôle de combler ce vide. de la population militaire et sur les modalités de prise - La troisième raison, enfin, est le lieu de présentation en charge appropriées de l’accident d’envenimation. du sujet qui est tout à fait pertinent – En effet, un Correspondance: Congrès de Médecine Militaire et/ou une revue de Pr. D. BACHA Médecine Militaire nous paraissent tout à fait indiqués Military Central Hospital Infectious Diseases Unit tant la population militaire, par la nature de ses mis- DZ-16000 Algiers, Algeria sions, est très exposée à ces accidents et les médecins E-mail : [email protected] VOL. militaires doivent, en conséquence, être préparés pour * Présenté au 38ème Congrès Mondial de Médecine Militaire, 83/3 leur prise en charge. Kuala Lumpur (Malaisie) 4-9 octobre 2009

International Review of the Armed Forces Medical Services 55 Revue Internationale des Services de Santé des Forces Armées Tableau des envenimations scorpioniques en milieu militaire Les mœurs du scorpion sont liés à l’éco système des Années 2002-2008. zones désertiques et chaudes : ainsi, étant photo- phobes, c’est-à-dire sensibles au rayonnement solaire, ANNÉES 1RM* 2RM 3RM 4RM 5RM 6RM TOTAL leur activité va s’exercer essentiellement la nuit, 2002 0 0 0 29 0 92 123 lorsqu’ils sortent à la recherche de leur nourriture : cafards, insectes… qu’ils trouvent dans les ordures, 2003 0 2 21 45 0 0 68 W.C, latrines, endroits sales… 2004 18 8 96 156 0 21 299 Le jour, ils recherchent les endroits frais et humides : 2005 32 0 86 191 0 59 368 sous une roche, dans un buisson, dans les fissures des 2006 41 0 122 227 0 34 424 murs d’habitations. 2007 57 21 233 189 36 184 720 L’influence des perturbations atmosphériques spéci- 1ER SEMESTRE 12 11 52 59 12 69 215 fiques du Sahara va également avoir des incidences sur leur comportement – les vents de sable excitent les TOTAL 160 42 612 896 48 459 2217 scorpions, qui deviennent alors plus dangereux. C’est à * RM : région militaire. ce moment que les piqûres sont les plus fréquentes.

RAPPELS SUCCINTS Quelle est la situation en Algérie ? Les Scorpions sont apparus sur terre, il y a quelques Il n'y a malheureusement pas de travaux sur ce sujet, 400 millions d’années. Les fossiles de l’ère primaire tout juste un début de prise en charge du problème (silurien) montrent une morphologie comparable à amorcée depuis 1987. celle des scorpions actuels. Les seules études existantes datent de l’époque coloniale, Les scorpions appartiennent à cette faune spéciale grâce aux travaux menés, notamment, par SERGENT et d’animaux inférieurs appelés les arachnides. Ils se sin- VACHON de l’Institut PASTEUR D’ALGER. gularisent par certaines caractéristiques : - 1. Ils sont poïkilothermes : dénués d’un système propre Les espèces fréquemment rencontrées dans notre pays de régulation thermique, comme les animaux supérieurs. sont les suivantes : Leur température varie avec la température extérieure. 1. Andoroctonus Australis : - 2. Leur activité biologique est rythmée par la tempé- - Grand (9 cm). rature extérieure. Elle est élevée lorsque la température - Jaune à pinces noires. extérieure est élevée (régions chaudes du globe). Elle est - Venin très toxique. abaissée lorsque la température extérieure est basse. - Scorpion très dangereux « le tueur d’hommes ». - Sahara oriental. C’est donc tout naturellement que, pour survivre et se perpétuer, le scorpion va élire domicile dans les régions 2. Buthus occitanus : chaudes du globe : Déserts de l’Inde, Amérique du sud, - Petit. USA, Mexique. Dans ce dernier pays, les piqûres de scor- - Jaune clair. pions posent un véritable problème de santé publique, - Tell + sud-ouest. impliquant la nécessité de recourir à des vaccinations de masse. 3. Scorpion maurus : - Petit. L’Algérie dont les trois quarts de la superficie sont un - Jaune brun. désert chaud, va tout naturellement être une des - Responsable d’accidents hémolytiques. régions du monde habitée par cette faune, inutile voire dangereuse, que sont les scorpions et les serpents et Morphologiquement, ils sont presque identiques : une tête, qui représentent un danger pour la vie humaine : des pinces et une queue avec telson terminal venimeux. La stabilité morphologique des scorpions contraste Les régions du sud du pays connaissent ce problème, avec avec la variabilité de leurs toxines. une recrudescence durant la saison chaude. Le « triangle de la mort » OUARGLA – BOUSSAADA – BISKRA est un Il y a une plasticité des toxines, selon l’espèce, en quan- espace particulièrement redouté. tité et en qualité : ainsi on distingue 13 pour Buthus occitanus et 6 pour Androctonus. Dans une ville ou une région donnée, il y a des sites ou des quartiers bien localisés et bien connus pour la fré- L’étude biochimique du venin permet de montrer qu’il quence des piqûres de scorpions : est composé de nombreuses protéines toxiques : Neurotoxines, Enzymes (phospholipase A2). - OUARGLA : QUARTIER RASSOULT. VOL. - BISKRA : SIDI OKBA. D’autre part le taux de toxine varie d’une espèce à l’au- 83/3 - MSILA : Les 4 Communes. tre, et d’une région à l’autre.

International Review of the Armed Forces Medical Services 56 Revue Internationale des Services de Santé des Forces Armées Pour survivre, le scorpion va donc rechercher sa nourri- Stade 2 ture là où l’homme jette ses détritus qui attirent les - Signes locaux + signes généraux (sueurs, nausées, insectes et les cafards, eux-mêmes nourris aux mêmes vomissements, diarrhée, modification du pouls et de la endroits. tension artérielle…). Les ordures ménagères étant alentours de l’homme, près des habitations, le scorpion va donc élire domicile Stade 3 tout près : sous les pierres, dans les fissures de murs des Caractérisé par : maisons, sous les décombres. là ou l’enfant va généra- Fièvre, troubles conscience profonds, troubles cardio- lement jouer, mettre sa main. vasculaires (tension artérielle basse, accélération du Les piqûres de scorpion sont des accidents redoutables, pouls), Troubles respiratoires (encombrement, cyanose, angoissants, spectaculaires et parfois tragiques. œdème aigu du poumon).

Quelques observations historiques permettent d’illus- Ce tableau peut se constituer au bout de 2 H. trer toute la gravité des piqûres de scorpion. Stade 4 Obs. n° 30, 1941 : Dr R. FAURE, à In SALAH. Enfant de Stade neurotoxique, dès la 2ème H après la piqûre. 23 mois, piqué à l’abdomen par un scorpion. Pas de - Coma profond, calme ou agité. sérum. Mort « quasi instantanée ». - Etat de choc avec collapsus cardio-Vasculaire. Obs. n° 2, 1941 : Dr CHABANNE - TOUGGOURT. Enfant - Troubles respiratoires. de 4 ans, piqué au pied par un scorpion. Pas de sérum. - Fièvre, le souvent à 39 °C. Mort quinze minutes. - Vomissements.

Obs. n° 27, 1939 : Dr VAUDIN, à Colomb-Bechar. Enfant Les Stades 3 et 4 nécessitent une réanimation. de 3 ans piquée à la nuque par un scorpion. Pas de sérum. Mort en vingt minutes. CONDUITE A TENIR Il y a donc nécessité impérieuse d’injecter le sérum anti - Toute piqûre de scorpion est a priori grave. scorpionique sans perdre une minute après une piqûre - La victime panique et l’entourage et quelquefois le du scorpion, lorsque les symptômes d’envenimement médecin veut à tout prix faire un geste d’urgence. sont graves d’emblée. D’où le principe : Reçu pour publication le 29 octobre 1943. * De mettre en observation (quelques heures) les Arch. Inst. Pasteur d’Algérie XXI. n° 4, décembre 1943. malades qui arrivent aux stades 1 et 2.

EVALUATION CLINIQUE * D’hospitaliser ceux qui s’aggravent et ceux qui arri- (CLASSIFICATION PAR STADE) vent aux stades 3 et 4. Stade 1 BUTS DU TRAITEMENT - Signes locaux : variables, courte durée. - Douleur aiguë au point d’inoculation. - « Barrer la route » au venin : entraver sa diffusion. - Engourdissement local. - Neutraliser ses toxines au maximum. - Eventuelle réaction inflammatoire. - Traiter de façon symptomatique les désordres engendrés.

➙ sans oublier l’éventuelle sérovaccination anti- tétanique.

Ce qu’il ne faut pas faire : - Placer un garrot. - Recourir aux moyens traditionnels •Gaz •Brûlures •Scarification •Succion

Ce qu’il faut faire : 1. Déposer sans frictionner une compresse imbibée d’antiseptique au point de piqûre.

2. Calmer la victime (et son entourage). VOL. Repos strict et immobilisation de la partie concernée 83/3 par la piqûre.

International Review of the Armed Forces Medical Service 57 Revue Internationale des Services de Santé des Forces Armées Utiliser antalgiques (acide acétylicylique, dérivés • Cœur. pyrazolés, glafénine…). • et autres (foie, rein…). Associer un tranquilisant en cas d’anxiété, (hydro- xyzine, clorazépate, procalmadiol). - Atteinte polyviscérale : Antispasmodiques (amidopyrine). La thérapeutique fait appel aux techniques et drogues habituelles de réanimation (diurétiques, toniques car- 3. Sérum antiscorpionique (S.A.S). diaques, oxygène, liberté des voies aériennes…). Théoriquement, c’est le traitement spécifique de cet accident. Il s’agit d’un sérum antitoxique purifié de Que faire sur le plan de la prévention ? l’Institut PASTEUR d’Alger, qui présente une spécificité Il faut avoir à l’esprit les éléments de bioécologie essen- croisée entre espèces de scorpions et dont il ne faut pas tiels du scorpion : négliger l’effet psychologique, rassurant. - Le scorpion est attiré par : - l’humidité. Mais, ne pas perdre de vue : - la nourriture (cafards, insectes). La Rapidité extrême de diffusion de la toxine. - La période de reproduction mai/juin. Le Risque d’accident sérique (S hétérologue). - L’activité nocive augmentée par la chaleur et les vents de sable. EN PRATIQUE : * Si la piqûre date de plus de 3 heures = éviter la séro- D’où la nécessité de mise en œuvre de mesures liées à : thérapie. - Education sanitaire : * Si la piqûre remonte à moins de 3 heures = injection - Information et sensibilisation des personnels. de S.A.S - Le médecin de l’unité doit insister sur : - ½ en sous cutanée à proximité du point de - Les mesures de protection individuelle/physique. piqûre. - La vigilance en périodes de vents de sable. - ½ en intra musculaire. (Méthode de BESREDKA, à portée : Adrénaline, Autres moyens : Corticoïdes et Antihistaminiques). - Prédateurs : - Oiseaux domestiques, poulet, canard, hérisson. D’autres médicaments jouent un rôle important : Ce moyen est difficile à envisager dans les unités militaires.

4. ATROPINE : Enfin, loin de toute formation sanitaire : Pharmacologie : l’atropine inhibe les effets muscari- - La trousse du médecin ou de l’infirmier doit contenir niques et les effets de la sérotonine et de l’Histamine. - S.A.S. Son intérêt est diversement apprécié dans une enveni- - Médicaments contre le choc. mation scorpionique. - Seringues jetables.

En règle : • En bivouac : * Utilisation dès l’apparition de signes muscariniques - Assainissement du site de stationnement du déta- (tachycardie, transpiration, vomissements, diarrhée). chement ou l’unité, et alentours (rayon de 400 - 500 m). * S/réserve de l’absence de contre-indications (glaucome). - Interposition de barrières individuelles (vêtements * IV (action immédiate, IM (action en 15 mn). adaptés). - Utilisation de répulsifs/alentours (à renouveler 5. CORTICOIDES : toutes les 2 à 3 heures). - Action anti-inflammatoire. - Hygiène générale : - Amélioration de la résistance capillaire. * Hygiène des unités et campements. Les utiliser tôt (petit effet de prévention de l’anaphy- * Destruction des gîtes éventuels autour des unités laxie éventuelle du venin et du S.A.S) (rayon de 400 à 500 m). - IV (hémisuccinate d’hydrocortisone HHC) ou IM * Ramassage approprié des ordures. (H.H.C, dexaméthasone, soludécadron). * Réparation des fissures murales. Attention aux effets indésirables. * Hygiène des toilettes ou des latrines. 6. Antihistaminiques : - Utilisation d’insecticides au niveau gîtes : - Action antagoniste de l’histamine (médiateur chi- * Action indirecte/cafards, moustiques. mique prédominant de l’anaphylaxie). * Action directe sur les scorpions. - Effets analgésiques, antithermiques, et antiémé- tiques minimes, mais appréciables. La prise en compte de la nocivité des insecticides, doit guider le choix du produit. 7. Réanimation de l’envenimation grave : * Dans l’envenimation scorpionique : AU PLAN GENERAL - Libération Acétycholine et de catécholamines. - Lésions périphériques multifocales de type sym- - Mise en place d’une surveillance épidémiologique des pathique ou parasympatique. piqûres de scorpion VOL. - Affinité des toxines pour : • Notification des piqûres de scorpion. 83/3 • Cellule nerveuses. • Identification des espèces de scorpion en cause.

International Review of the Armed Forces Medical Service 58 Revue Internationale des Services de Santé des Forces Armées • Enquête épidémiologique. de cas, avec plusieurs dizaines de cas mortels, sont • Echange d’informations avec les services compé- enregistrés chaque année. tents de la santé publique. Un programme national de lutte contre l’envenimation - Projet de cartographie des espèces de scorpions en scorpionique a été engagé dès les années 80. circulation. En milieu militaire, en dépit d’une nette réduction de l’incidence enregistrée ces dernières années, environ 300 cas CONCLUSION sont encore observés chaque année, touchant notam- Soulignons : ment des militaires exposés au risque de contact avec les scorpions dans les zones réputées « à scorpions ». * L’importance de la morbidité et de la mortalité de l’envenimation scorpionique, avec retentissement sur En conséquence, les services de santé militaire ont la disponibilité opérationnelle des unités exposées. adopté des mesures appropriées de prévention et de prise en charge des victimes. * La nécessité de rationaliser la thérapeutique pour réduire l’incidence des cas dramatiques et avoir à l’es- BIBLIOGRAPHIE prit que la « panacée - S.A.S » répond à des règles d’uti- ANSEL D’IMEUX : Envenimations par animaux terrestres. lisation bien définies, afin de ne pas aggraver la situa- E.M.C Paris Intoxications. 1979; 2 16078 A10: 4-10. tion. BAWASKAR H.S. : Scorpion sting : Trans. Rev. Soc. Trop. Med. et Hygiène, 1984,78: 414-5. * La place importante de la réanimation dans l’envenimation scorpionique grave. BAWASKAR H.S. : Diagnostic cardiac premonitory signs and symptoms of red scorpion stings. Lancet. 1982; 1: En matière de Prévention : 552-4 * L’information de la population militaire. BENSALAH M., SELLAMI A., OLIVIER Ph. Les envenimations scorpioniques graves à propos de 21 cas traités au * Les mesures indirectes de nature à diminuer la cours de l’année 1976. Tunis Med. 1978; 56: 415-23. population de scorpions et à éviter le contact scorpion- homme. FREJAVILLE JP. , BISMUTH C., CONSO F. Toxicologie clinique. 3ème éd. Paris, Flammarion Médecine Sciences 1981; pp34- Perspectives : 37, p. 341. GUEDICHE M., LASSOUED M., EL-ATROUS L. Les complica- * Les axes de recherche devraient porter sur la réalisa- tions cardiovasculaires au cours des envenimations acci- tion de la cartographie des espèces de scorpions et l’af- dentelles par scorpion. (A propos de 90 cas). Tunis Med. finement des essais d’utilisation des insecticides à 1979; 57 : 328-30. grande échelle. GOYFFON. M., CHIPPAUX. J.P. Les Accidents d’envenimement en France. (faune terrestre autochtone). Médecine RÉSUMÉ & Armées. 1990; 18 : 83-6 . Les piqûres de scorpion représentent un réel problème VACHON M. Etude sur les scorpions. Institut Pasteur de santé publique en Algérie. Des dizaines de milliers d’Algérie. Ed. Alger 1952; 1: 487.

VOL. 83/3

International Review of the Armed Forces Medical Service 59 Revue Internationale des Services de Santé des Forces Armées The War Veterans’ Silent Killers. ARTICLES ARTICLES ARTICLES ARTICLES

By E. GERDING. Argentina

Eduardo César GERDING

Dr. Eduardo César Gerding was born in Buenos Aires on August 23rd, 1950 and joined the Argentine Navy in 1976. He was the first physician assigned to the transport ship ARA “Canal Beagle” during the 1978 conflict with Chile. Since 1987 till 1990 he was appointed Chief of the Medical Department of the Marine Corps 5th Battalion in Río Grande (Tierra del Fuego). Former Chief of Gastroenterology at the Buenos Aires Naval Hospital. He retired as Lieutenant Commander Medicine Doctor. Member of the Roddis Society for the History of Navy Medicine (USA). Founder in Argentina of the SARRRAH Project together with the University of Lübeck and the DGzRS (German Maritime Rescue Service). In 2006, after his lecture at Willoughby Hall (University of Nottingham) he founded in Argentina the Nottingham-Malvinas Group. Dr Gerding is the nation wide Medical Coordinator of the Malvinas War Veterans’Health Department at the INSSJP. In September 2008 was appointed Member of the Scientific Committee of the International Review of the Armed Forces Medical Services.

RÉSUMÉ Les tueurs silencieux des anciens combattants. Voici maintenant 27 ans, les forces britanniques et argentines s’affrontaient dans ce qui fut considéré comme la dernière guerre coloniale de la Grand Bretagne. Les combattants des deux camps affrontent maintenant un ennemi commun : les maladies cardio-vasculaires (MCV) qui deviendront plus évidentes alors que passent les années. Il existe de grandes similitudes entre l’Argentine et le Royaume-Uni en matière de facteurs de risque coronarien (FR). Les effets psychologiques tardifs du conflit de 1982 sont liés aux MCV. Les effets psychologiques peuvent hâter l’apparition de troubles cardiaques aigus.

KEYWORDS: Veterans, Cardiovascular Diseases. MOTS-CLÉS : Vétérans, Maladies cardio-vasculaires.

CARDIOVASCULAR DISEASE (CVD) Department of Veterans Affair (VA) healthcare system for the first time, who were mostly in their 20s and 30s Cardiovascular disease (CVD) is any disease of the circu- were significantly more likely to display certain cardio- latory system. Most of the deaths from CVD relate to vascular-disease risk factors if they had received a men- coronary heart disease (CHD or heart attack), stroke tal-health diagnosis such as depression, anxiety disorder (Cerebrovascular disease) and other diseases of the cir- or (PTSD)24. The Committee on Gulf War and Health has culatory system including heart failure and diseases of stated that many of the studies published so far were the arteries97. A major study, conducted by researchers at cross sectional and couldn’t fully assess symptom dura- the Harvard School of Public Health in Boston (USA), of tion and chronicity, latency of onset, and prognosis. about 2000 military veterans who served in the armed forces during WWII proves that they suffer from symp- This was an important limitation because many of the toms/of posttraumatic stress disorder (PTSD). The study long-term outcomes such as coronary heart disease and also suggests that they stand a greater risk of heart cancer have long latent periods of decades46, 55. No stu- disease as their live unfold106. In Russia, veterans of the dies have been made so far regarding the actual and Great Patriotic war have shown an earlier development future risk of cardiovascular health of Argentine and of ischemic heart disease, arterial hypertension, and VOL. British war veterans who took part in the 1982 conflict. cerebral atherosclerosis6. Cohen et al studied Veterans of 83/3 We could very well quote Patrick and Heaf in as far as the US Wars in Afghanistan and Iraq using the there is «a paucity of research on war victims»81.

International Review of the Armed Forces Medical Services 60 Revue Internationale des Services de Santé des Forces Armées CORONARY HEART DISEASE (CHD) RISK FACTORS (RF) CHD is a disease that affects the heart muscle and the At least nine risk factors (RF) can help predict the like- blood vessels. The most serious danger of CHD is a lihood of CHD: heredity, being male, advancing age, heart attack, which occurs when the supply of blood to cigarette smoking, high blood pressure, diabetes, obe- the heart is greatly reduced or stopped due to a sity (especially excess abdominal fat), lack of physical blockage in a coronary artery97. By the time Argentine activity, and abnormal blood cholesterol levels. war veterans have 66 years old it is expected that 7 of According to Dr. Gregg C. Fonarow Cardiology every ten deaths will be due to non transmitable Professor at California University (Los Angeles, USA) diseases; among them coronary heart disease (CHD) will probably the three most serious RF are cigarette smo- be the main cause and stroke the fourth41. king, high blood pressure and abnormal cholesterol levels. Several of these risk factors are interrelated. CONGESTIVE HEART FAILURE (CHF) Obesity, lack of exercise, and cigarette smoking can raise blood pressure and adversely influence blood CHF is a disorder where the heart loses its ability to cholesterol levels. Several studies suggest that expo- pump blood efficiently, leading to problems like sure to environmental tobacco smoke ("passive smo- fatigue and shortness of breath. CHF is not a single king") also increases the risk of developing heart disease but the end stage of many different forms of disease8, 94. heart disease. The most common of these is CHD. HEREDITY (INCLUDING RACE) CVD MORTALITY Researchers have identified more than 250 genes that According to the American Heart Association about may play a role in Coronary Artery Disease (CAD). The 82% of people who die of coronary heart disease are 65 polygenic effect means that the genetics of CAD are or older1. CVD are the first cause of mortality and mor- extremely complicated with many different genesin- bidity in Argentina83. In 2007, of 290,911 deaths in fluencing a person’s risk. A mutation gene is responsi- Argentina, 95.420 were due to CVD89. There are 42,0. ble for familial hipercolesterolemia (FH). Mutations in myocardial infarcts (MI) per year in Argentina88. the apo E gene affect blood levels of LDL. More than 30 Cardiovascular diseases are the first cause of mortality in mutant forms of apo E have been identified. Mutations Olavarría (Province of Buenos Aires)83. On the other of Apolipoprotein B-100 result in LDL staying in blood hand UK has one of the highest death rates from CVD for longer than normal. People with high levels of a in Europe with 200,000 deaths annually, a third of the particle called Lp (a) in blood have higher risk of deve- total58. In England, coronary heart disease (CHD) kills loping CAD. Mutations in the Apolipoproten A1 gene more than 110,000 people in every year. More than result in low HDL levels and early heart attacks. The gly- 1.4 million people suffer from angina and 275,000 peo- coprotein IIb/IIIa gene was mutated in half of patients ple have a heart attack annually. Such statistics mean under 60 who were admitted to a hospital intensive CHD is the biggest killer in UK. The Government is com- care unit with CAD. In general, test for specific genetic mitted to reducing the death rate from CHD, stroke and mutations are not performed in CAD100.African related diseases in people under 75 by at least 40 per- Americans have more severe high blood pressure than cent - to 83.8 deaths per 100,000 population by 2010. Caucasians. Heart disease is higher among Mexican (UK DH Department of Health). Betty McBride, Director Americans, American Indians, native Hawaiians and of Policy & Communications at the British Heart some Asian Americans1, 66. Foundation said that compared to other countries in Europe, the UK remains in the red zone when it comes MALE SEX (GENDER) to tackling premature death from heart disease79, 84. The lifetime risk of developing CHD after age 40 is 49% CVD PREVALENCE for men and 32% for women. The incidence of CHD in women lags behind men by 10 years for total CHD and Two important research studies have been made on the by 20 years for more serious clinical events such as MI impact of cardiovascular diseases on the Argentine and sudden death1. population: the national survey on Risk Factors led by the Health Minister and the CARMELA (Cardiovascular SMOKING Risk Factors Multiple Evaluation in Latin America) research developed by the InterAmerican Heart According to the Argentine Health Minister, about Foundation15, 43, 90. In Buenos Aires, according to CAR- 4 million people smoke and 40,000 die per year as a MELA, 12.1 percent of people between 25 and 64 years result of smoking. About 6,000 are passive smokers. presented a high cardiovascular risk according to Argentina is second in the world rank regarding smo- Framingham score meaning a risk above 20 percent of king exposure at homes. 69 percent of children are suffering a myocardial infactation or a stroke in the fol- exposed to smoke at home. According to CARMELA in lowing 10 years. The same study revealed that the 25- Buenos Aires 39.7 percent of men and 37.7 percent of 34 years old inhabitants of Buenos Aires had their caro- women smoke. We are third in an international rank VOL. tid arteries affected by atherosclerosis in the same pro- whose first position is occupied by Quito, (Ecuador) 83/3 portion than the 55-65 years old inhabitants of Chile87. where 49.4 percent of men are smokers89.

International Review of the Armed Forces Medical Services 61 Revue Internationale des Services de Santé des Forces Armées Smoking fell to its lowest recorded level in 2007, 21 per- rise in systemic arterial pressure and an increase in pro- cent of the population of Great Britain aged 16 and over. teinuria, as well as a progressive risk for developing Smoking is highest in the 20-24 age group (31 percent) renal injury. Greater dietary salt consumption results in and lowest among those aged 60 and over (12 percent). a rise in glomerular filtration fraction and increasing Married or cohabiting people smoke less (18 percent) proteinuria. The pressor response to increasing dietary than singles (28 percent). Cigarette smoking is lower salt consumption in patients with diabetes and hyper- among households classified as professional and mana- tension may be related to insufficient renal vasodila- gerial (15 percent) than among those classified as routine tion. (Weir, Matthew-Mineral Electrolyte Metab and manual (26 percent). Health concerns are the most 1998;24:438-445). commonly mentioned reason for quitting, with 86 percent of people who want to give up mentioning at least A recent research has shown that people consuming one health reason. After health, the next most commonly diets of 1,500 mg of sodium had better blood pressure mentioned reasons are costs (27 percent), family pressure lowering benefits. These lower-sodium diets also can (20 percent) and the effect on children (15 percent)76. keep blood pressure from rising and help blood pressure medicines work better92. OBESITY According to data of the Argentine Cardiology Body mass index (BMI) is a simple index of weight-for- Association the average intake of salt of 12 g per day height that is commonly used in classifying overweight (4 kg per inhabitan per year). An acceptable amount and obesity in adult populations and individuals. It is would be 5 g/day and for patients with high blood defined as the weight in kilograms divided by the pressure is 2 g. (Shapira, Valeria-Alerta sobre el daño square of the height in meters (kg/m2). The World que provoca la sal-La Nación 20 de marzo de 2002). Health Organization (WHO) defines "overweight" as a BMI equal to or more than 25, and "obesity" as a BMI On average, UK salt intakes are approximately 10.1 g equal to or more than 30. These cut-off points provide per day in men and 7.7 g per day in women but range a benchmark for individual assessment, but there is evi- from 4 to 18 g per day in men and 3 to 14 g per day in dence that risk of chronic disease in populations women. Sodium naturally present in food accounts for increases progressively from a BMI of 21. about 15%, and salt added to food during manufac- ture or processing accounts for the difference i.e. 60 to Vieweg et al found significantly higher levels of over- 70% of total sodium intake19. The US sodium RDA of weight and obesity among male war veterans with less than 2,400 mg is higher than the UK Recommended (PTSD) in the USA than in the general population. (J Natl Nutritional Intake (RNI) whose upper limit for sodium is Med Assoc. 2006 April; 98 (4): 580–586.). 1,600 mg.

According to the CARMELA study among inhabitants of LACK OF PHYSICAL ACTIVITY Buenos Aires obesity in men was 23.1%, in women 16.8%, diabetes 7.9% and metabolic syndrome 21.7%87. About 46% 46.2 percent of Argentine adults lack of physical acti- of men in England and 32% of women are overweight (a vity89. Six of every 10 Argentines lack of physical acti- body mass index of 25-30 kg/m2), and an additional 17% of vity93. Recent statistics suggest that seven out of ten men and 21% of women are obese (a BMI of more than 30 British adults don’t do enough physical activity and this kg/m2). Overweight and obesity increase with age. About increases their risk of heart disease16. 28% of men and 27% of women aged 16-24 are overweight or obese but 76% of men and 68% of women aged 55-64 The UK government calculates there's been a decline of are overweight or obese. The percentage of adults who are more than 20 percent in the number of miles walked obese has roughly doubled since the mid-1980's. Obesity is since the mid-1980s9. more common in adults employed in manual occupations, particularly in women. A quarter of women working in uns- EXCESSIVE ALCOHOL INTAKE killed manual occupations have a BMI of more than 30 kg/m2 compared to one in seven of those employed in a professio- Drinking too much alcohol can raise blood pressure, nal role. Both men and women working in unskilled manual cause heart failure and lead to stroke. It can contribute occupations are over four times as likely as those in profes- to high triglycerides, cancer and other diseases and sional employment to be classified as morbidly obese103. produce irregular heartbeats. The risk of heart disease Several Studies have evaluated BMI as a risk factor for left in people who drink moderate amounts of alcohol is ventricular remodelling and overt heart failure. lower than in nondrinkers. One drink is defined as 4 fl oz of wine or 12 fl oz of beer1. Even low estimates of Obesity has been consistently associated with left ven- 5% or 7% of hypertension attributable to alcohol imply tricular hypertrophy and dilation which are known that there are more patients with hypertension caused precursors of heart failure56. by alcohol than by conventional causes of remediable secondary high blood pressure57. Researchers found SODIUM that 45 percent of the people who began drinking before the age of 14 developed later alcohol depen- VOL. 83/3 Patients with hypertension and diabetes are frequently dence, compared with only 10 percent of those who salt-sensitive. Increasing dietary salt intake result in a waited until they were 21 or older to start drinking45.

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© 2010 Alere. All rights reserved. 11ALE0758EN Since 2000 the beer intake in Argentina keeps a steady renal failure. Therefore aggressive therapy is warran- trend of 12 lt/person/year. Since 1980 the wine intake ted to reduce blood pressure to recognised targets. In dropped 30% but in that same period beer intake England only around 20% of hypertensive men and increased 500%. The alcohol intake among youth 30% of hypertensive women receive treatment for increased 40%37. Certain provinces like La Pampa have their condition. This means that a staggering two- a wine intake of 60.31 lt/person/year26, 38. thirds with the condition remain hypertensive. An estimated 22,601 first MIs and at least 78,000 strokes In England in 2005, 73 percent of men and 58 percent could be prevented by reducing blood pressure to of women reported drinking an alcoholic drink on at optimal levels. In UK hypertension-attributable MIs least one day. Thirteen percent of men and 8 percent of and strokes are estimated to account for 974.4 BP per women reported drinking on every day in the previous year in hospital and surgical costs18. week. Younger people were more likely to drink hea- vily, with 42 percent of men and 36 percent of women DIABETES aged 16-24 drinking above the daily recommendations, compared to 16 percent of men and 4 percent of In Argentina the adjusted rate of prevalence for dia- women aged 65 and over. Among men, 24 percent betes is 7,6%25, 60.New figures by the Yorkshire and reported drinking on average more than 21 units in a Humber Public Health Observatory reveal that more week. For women, 13 percent reported drinking more than one in ten (11.6 percent) deaths among 20 to 79- than 14 units in an average day75. In Great Britain in year-olds in England can be attributed to diabetes. If 2007/8 the litres of pure alcohol per adult were Beer: current trends continue, one in eight (12.2 percent) 4.49, Wine: 3.80, Spirits: 2.40, Cider: 0.84, Total alcohol: deaths among 20 to 79- year-olds will be attributable 11.53. to the condition by 2010. This work is based on data that shows adults under 80 with diabetes are around The Family Expenditure Survey shows that in 2005/6, of twice as likely to die as those without the condition the average weekly household expenditure on alcoholic and women with diabetes have a greater increased risk drink of £14.80, £ 8.50 was spent in on-licensed premises of death compared to their male counterparts. and £ 6.30 in off licences, including supermarkets36. (Medical News Today: http://www.medicalnewstoday.com/articles/117896.php). HIGH BLOOD PRESSURE There are about 35,000 deaths a year in the UK attri- Reducing blood pressure to an optimal level has been butable to diabetes about one in twenty of all deaths. estimated to reduce the 10 year risk of CHD by 22.57% Approximately 30-80% of patients with Type 2 diabetes in an otherwise average man and 33.47% in an other- are also hypertensive18. wise average woman. A long-term reduction in DBP of 5-6 mmHg has been demonstrated to correlate with a ABNORMAL BLOOD CHOLESTEROL LEVELS 35-40% reduction in risk of stroke14. Studies show that the relationship between CHD and In Argentina high blood pressure prevalence is between cholesterol is continuous, and that as levels of choles- 27.6% and 28.9%. Between 50 and 59 years old its terol decrease, heart health risk continuously decreases 49.7% but increases to 65% in older than 60 years old. alongside it. According to the Argentine Cardiology The same results were observed in the Coronary Risk Association and the Argentine Cardiology Federation, Factors Multicentric surveillance (EMSAC, FR)25. It’s esti- in Argentina 60 percent of cardiovascular diseases are mated than only 18% of hypertensive patients are well linked to blood cholesterol values above 200 mg/dl controlled32. Prevalence of high blood pressure among which increases 49 percent the chances of suffering a the Wichi-Chorote indians at Santa Victoria Este (pro- myocardial infarct. One of every the Argentine older vince of Salta, Argentina) is less than other communities than 21 years has blood cholesterol values above like General Belgrano (39.8%) and Rauch (35.8%) but 200 mg/dl30. Based on combined data from prospective it’s very much like the one observed in other cities like studies, triglyceride is a risk factor for cardiovascular La Plata (32.7%) and Cordoba (29.85%) 23, 68. disease for both men and women in the general population, independent of HDL cholesterol49, 74. 43,625 people die from a hypertension-attributable myocardial infarction (MI) or stroke in England each In UK cholesterol is the single greatest risk factor for year. Hypertension also causes heart failure, peripheral CHD. Statistics show that raised blood cholesterol is a artery disease and is implicated in dementia. factor in nearly half of all CHD cases (47%). Raised cholesterol is also a major risk factor in the 110,000 strokes In the UK, the prevalence of cardiovascular disease, dia- suffered every year in the UK. Studies have shown that betes and hypertension is higher among Asian patients a 10% reduction in cholesterol (achievable by changes compared to the general population. Similarly, hyper- in diet and lifestyle) in a 40-year-old male would lead tension is very common among Afro-Caribbeans (The to a 54% reduction in CHD. largest proportion of the African-Caribbean population in the UK are of Jamaican origin); affecting half of The Health Development Agency recently published a VOL. 83/3 those aged 40 years and over. As a result of these fac- report stating that "reducing cholesterol levels by even tors these ethnic groups are at high risk of stroke and a small amount would prevent approximately 25,000

International Review of the Armed Forces Medical Service 64 Revue Internationale des Services de Santé des Forces Armées fewer deaths each year. This is quite possible". Even those 32 percent of those infected die from organ damages individuals with a family history of high cholesterol levels during the chronic phase. Two of every 10 cases of severe can improve their health outcomes through diet and life- damages to the heart caused by Chagas disease occur in style changes. Unfortunately, only 5% of the British people between the ages of 20 and 40. Right bundle- population and, even more worryingly, only 4% of GPs branch block or left anterior hemiblock precedes other recognise cholesterol to be the major risk factor for CHD. manifestations of chronic heart disease in the majority Most think that smoking is the greatest risk factor. of cases. Progression of disease leads to cardiac dilata- (Memorandum by Cholesterol UK (WP 85) Parliament). In tion and biventricular failure. Prominent features of UK, a study by the Care Quality Commission on the per- advanced Chagas heart disease include left ventricular formance of 8300 GP practices and 152 primary care apical aneurisma and combination of complex ventricu- trusts to cut deaths from heart disease and reduce ine- lar arrhythmias, sinus bradyarrhythmias, and intraventri- qualities found that death rates have fallen largely cular and atrioventricular conduction block. The most because of reductions in smoking and cholesterol levels58. common modes of death are sudden death, progressive heart failure, and to a lesser extent, embolism of mural CHAGAS DISEASE thrombi to the brain or other organs. The prognosis for patients with Chagas cardiomyopathy may be worse Chagas disease affects 16–18 million people as of 2008, than that associated with other dilated cardiomyopa- with some 100 million (25% of the Latin American popu- thies71. Rassi et al reported their evaluation of 424 lation) at risk of acquiring the disease, killing around patients with known Chagas heart disease as the basis 20,000 people annually. The disease is present in 18 coun- for a risk score to predict the likelihood of death86. tries on the American continent, ranging from the southern United States to southern Argentina. Among persons in the high-risk category the 10 year mortality was 84 percent. The two only existing drugs Chagas disease is transmitted by the reduviid bug (from benznidazol and nifurtimox are very effective in new- the Reduviidae family and the Triatominae subfamily), born and breastfeeding children but only 60 to 70 per- also known as the vinchuca2, 4, 47, 95. The insect lives in cre- cent of adolescents and adults are successfully trea- vices and gaps in poor rural housing such as thatch, mud ted42. The older the patients are the greater the likeli- or adobe huts in 18 Latin American countries. In hood they will experience side effects from the drugs21. Argentina the vinchucas are found throughout the coun- In 2007, WHO established The Global Network for try, but are especially prevalent in northern, western and Chagas Disease Elimination to raise global awareness central provinces where the climate is warm or tempe- of the disease20. On July 9, 2009 Doctors Without rate but dry. The infected reduviid bug transmits a pro- Borders launched a campaign to raise awareness of this tozooan parasite named Trypanosoma cruzi through its parasitic disease. faeces, which human victims unwittingly rub into the bite wound left by the bug, or into their eyes, mouth or nose. In the UK no cases transmitted by transfusion have The parasites thus enter the victim’s bloodstream and been reported. (UK Blood Transfusion & Tissue gradually invade most organs of the body, often causing Transplantation Services). severe damage to the heart, digestive tract or nervous system. HOMOCYSTEINE There are 2 million people (5% of the population) infec- Homocysteine is an amino acid in the blood107. ted with Chagas in Argentina. The northern province of Epidemiological studies have shown that too much Chaco (927 war veterans with 677 wives and 2,454 homocysteine in the blood (plasma) is related to a sons/daughters) concentrates 15 percent of all the cases. higher risk of coronary heart disease, stroke and peri- For every case notified there are 20 cases undiagnosed pheral vascular disease. Other evidence suggests that 31. Seven percent of the 600,000 annual births in homocysteine may have an effect on atherosclerosis by Argentina are to women with Chagas disease. An ave- damaging the inner lining of arteries and promoting rage of four percent of these women pass the disease on blood clots. However, a direct causal link hasn’t been to their babies. established. Plasma homocysteine levels are strongly influenced by diet, as well as by genetic factors. The In the province of Santiago del Estero (152 war veterans dietary components with the greatest effects are folic with 101 wives and 367 sons/daughters) 90 percent of acid and vitamins B6 and B12. Folic acid and other B new cases are diagnosed in children less than 10 years old vitamins help break down homocysteine in the body. of which 30 percent are less than as year old. Several studies have found that higher blood levels of B vitamins are related, at least partly, to lower concen- The province of Santa Fe’ has 237 war veterans, 199 wives trations of homocysteine. Other recent evidence shows and 539 sons/daughters. In the Gato Colorado village that low blood levels of folic acid are linked with a (pop 1,500), 420 km from Rafaela (province of Santa Fe) higher risk of fatal coronary heart disease and stroke. more than 35 percent of its population are infected with Several clinical trials are under way to test whether Chagas50. lowering homocysteine will reduce CHD risk. Recent data show that the institution of folate fortification of VOL. Chagas disease develops slowly as the parasite can set- foods has reduced the average level of homocysteine in 83/3 tle in the body tissues, mainly the heart. An estimated the U.S. population.

International Review of the Armed Forces Medical Service 65 Revue Internationale des Services de Santé des Forces Armées Jendricko et al recently published a cross-sectional NEIGHBORHOOD AND study among 66 war veterans with PTSD, 33 without CORONARY HEART DISEASE PTSD and 42 healthy volunteers measuring serum concentrations of homocysteine, total cholesterol, Even alter controlling for personal income, education, high density lipoprotein cholesterol (HDL-C), low den- and occupation, living in a disadvantaged neighbourhood sity lipoprotein cholesterol (LDL-C) and triglycerides. is associated with an increase incidence of coronary heart Non smoking PTSD war veterans had higher homocy- disease34. steine concentrations when compared to non smoking 53 war veterans without PTSD In Buenos Aires, Villa Soldati and Villa Lugano are the neigbourhoods where more robberies with violent AIR POLLUTION assaults are observed67, 69. In 1997, the neighbourhoods of Ciudadela, Villa Ballester, San Martín, Caseros, Prospective epidemiologic studies showed that morta- Morón y Quilmes were considered no man’s land. In lity was increased among people living in communities 2004 many offenses were observed as well in Belgrano, with elevated concentrations of fine particulate air the microcenter, Balvanera, Barrio Norte and Bajo pollution. Subsequent research has shown that parti- Flores (La Nación, June 6, 2004). Poverty and unem- culate air pollution is statistically and mechanistically ployment are rampant in Villa 21-24 in Barracas (Critica linked to increased cardiovascular disease. The 22, October, 2009). Vehicles were mostly stolen in Women’s Health Initiative (WHI) observational study Ramón Falcon, Yerbal and Moldes street (CABA – broadens the scope by finding that nonfatal cardio- February, 2009). vascular events are also strongly associated with fine particulate concentrations35. The centre of Buenos In UK according to a research of a national insurer Aires has up to 14 ppm of CO (upper limit is 9 ppm). CO Nottingham has the worst burglary rate, followed by together with lead and other particles has increased Hull and Leeds. Residents in Guildford were found to since 199027. be the least at risk. People in SW11 in Battersea and Clapham were the most likely to have been burgled Air pollution in the UK has been a recognised problem during the past five years in London, followed by those as far back as the 13th century, when the use of coal in in the N8 district of Hornsey. Areas of Sheffield, London was prohibited on the ground that it was pre- Croydon and Hove also made it into the top 10 districts judicial to health. During the Industrial Revolution, in which burglaries were most likely to occur10, 11, 12. smog pollution in urban areas became a significant problem, due to the industrial and domestic burning of coal102. Today, both urban and rural smog pollution PSYCHOLOGICAL FACTORS AND CHD results from the build up of secondary photochemical pollutants such as ozone. Whilst industrial nitrogen Psychological factors may contribute not only to the oxides emissions have fallen in the last 15 years, emis- evolution of coronary atherosclerosis and long-term sions from road transport have grown significantly, risk of coronary heart disease, but also to the trigge- because of the increase in the number of cars, ring of acute cardiac events in patients with advanced although in the last few years the introduction of atherosclerosis. Acute anger, stress and depression or sadness may trigger an Acute Coronary Syndrome clean fuel technology has helped to reduce emissions. 5, 44 Similarly, emissions of particulates, carbon monoxide within a few hours in vulnerable individuals . The psy- and volatile organic compounds (VOCs) from road chobiological processes underlying emotional trigge- transport have increased, although as for nitrogen ring may include stress-induced haemodynamic res- oxides, these emissions are now starting to fall. ponses, autonomic dysfunction and parasympathetic withdrawal, neuroendocrine activation, inflammatory responses involving cytokines and chemokines, and OBSTRUCTIVE SLEEP APNEA (OSA) prothrombotic responses, notably platelet activation. These factors in turn promote coronary plaque disrup- Estimated prevalence of OSA among patients 30-70 tion, myocardial ischaemia, cardiac dysrhythmia and years old is 4% for men and 2% for women (Instituto thrombus formation39, 94. de Efectividad Clínica y Sanitaria-www. iecs.or.ar) Regardless of their own CAD status, people with OSA Long term traumatic stress and CHD are more likely than those without OSA to have a family history of premature CAD mortality. (Apoor S. Price published the factors leading to low rates of com- Gami et al. -Familial Premature Coronary Artery bat psychiatric casualties among British in the 1982 Disease Mortality and Obstructive Sleep Apnea- conflict85. Orner RJ et al reported the first available fin- CHEST, January 2007 vol. 131 no. 1, 118-121). dings on long term traumatic stress syndromes among British servicemen who are veterans of the Malvinas In UK 19-27% of patients with OSA had a motor vehi- War77. Then Gareth H. Jones and Jonathan W.T. Lovett cle accident due to falling asleep at the wheel. 34% of published three cases of British war veterans who took drivers who drove more than 20,000 miles a year part in Malvinas: A 19 years old Welsh Guard blown out admitted they had fallen asleep at the wheel during VOL. of a below deck compartment on the assault ship HMS 83/3 the previous 12 months. (1998 Guilleminot-OSA Sir Galahad by a bomb blast, a 36 years old naval ste- Online UK). ward who was a first aid orderly on HMS Antelope

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Photos and specifications are indicative and may change at any time without prior notice. Free DVD is now available! when a bomb with a faulty fuse decapitated his fiend Myocardial infarction and sudden cardiac death and later exploded blowing him into the water and demonstrate a marked circadian variation with an another Welsh Guard who suffered severe burns in a increased risk during the morning after awakening and bomb blast below decks on HMS Sir Galahad and was arising. Trigger factors occur relatively frequently and the only survivor from one of the stern compartments. may play a causative role in up to 20% of cases of acute They all demonstrated a common pattern similar to coronary syndromes. that shown by Vietnam war veterans regarding delayed psychiatric responses, particularly anxiety neu- CLASS AND MORTALITY roses54. Kulenovic et al determined plasma lipid parameters and calculated risk factors for 50 veterans in Differences in rates of premature health illness, and the PTSD group and 50 veterans in the non PTSD disability are closely tied to economic status. Class is dif- Group. Chronic PTSD was associated with dyslipemia, ficult to define. There are many ways of measuring it, leading to an increased risk of coronary artery disease. the most widely accepted being in terms of income, Post MI patients with PTSD have higher sympathetic wealth, education, and employment. Unhealthy beha- and lower parasympathetic heart rate modulation vior and lifestyles alone do not explain the poor health activity, compared with patients with MI and no of those in lower classes. Even when behavior is held as PTSD61. constant as possible, people of lower socioeconomic status are more likely to die prematurely than are people Depression of higher socioeconomic status. Some authors pinpoint income as the single most powerful predictor of morta- Depression is commonly present in patients with coro- lity62 and some analysts suggest that employment is the nary heart disease (CHD) and is independently associa- key socioeconomic determinant of health13. Policies ted with increased cardiovascular morbidity and morta- regarding education, taxes, recreation, transportation, lity65. Depression, anxiety, and hostility have each been and housing cannot be divorced from their effects on demonstrated to be associated with the risk of coronary health. Medical care has been estimated to account for heart disease and of adverse outcomes after acute coro- only about 10 to 15 percent of the nation’s premature nary events108. Several hypotheses have been proposed deaths70. Thus, ensuring adquate medical care for all will to explain such associations. O’Malley et al in a prospec- have only a limited effect on the nation’s health. tive study of 630 consecutive consenting, active-duty US Army personnel 39 to 45 years of age without known National averages show that poverty in Argentina has coronary artery disease found that depression, anxiety, been declining since 2003, when a record 54 percent of hostility, and stress were not related to coronary artery the country's 37 million people were below the poverty calcification and that somatization was associated with line after the economic and political collapse of late the absence of calcification. (O’Malley, P. et al- The New 2001. Statistics for late 2006 from the National Institute England Journal of Medicine 2000;343:1298-304). In of Statistics and Censuses (INDEC) showed that 26.9 some studies, nearly half of the veterans who had PTSD percent of the Argentine population was living in were also depressed. poverty. But in Corrientes, that figure was 46 percent. Indigence (extreme poverty) was 8.7 percent nationally, The two conditions often go hand in hand, often with but 18.1 percent in Corrientes. Children under 14, who some overlap in symptoms. "In the group who have are more numerous in low-income families, suffer from PTSD, depression is quite prominent, about 45 per- more and deeper poverty at all levels. In the country as cent," reports Frank Schoenfeld, MD, the director of a whole, 40.5 percent of children are poor. the PTSD program at the Veterans Affairs Hospital in San Francisco. In a study of 101 veterans with depres- In the northeastern provinces, the proportion is 60 per- sion, a report in the Journal of Mental Disorders sho- cent, and in Corrientes childhood poverty reaches 63.4 wed that compared to vets with no symptoms of the percent. INDEC uses two parametres to measure illness, "The depression group had experienced signifi- poverty. It defines as "indigent" people who cannot cantly higher numbers of traumatic incidents... and afford a basic basket of food representing their mini- more frequently met diagnostic criteria for PTSD"101. mum "energy and protein needs." The "poor" are those who cannot afford the "complete basket" which Emotional Stress in addition to the basic food basket contains goods and Physical exertion, burst of anger and sexual activity services such as clothing, transport, education and have been proven to have triggering potential. Other healthcare. According to INDEC's calculations, the basic possible triggers include external and environmental food basket costs around 40 dollars a month per person events such as earthquakes, war threat and climatic in the northeastern region, while the complete basket factors109. The Federation Internationale de Football is worth just over 85 dollars a month. The cost of the Association (FIFA) World Cup, held in Germany from baskets varies in different regions of the country. June 8 to July 9, 2006 provided an opportunity to exa- Indigence affects the lives of 14.3 percent of children mine the relation between emocional stress and the under 14 in Argentina overall, but in Corrientes the incident of cardiovascular events. Viewing a stressful proportion is 31 percent29, 105. VOL. soccer more than doubles the risk of fan acute cardio- 110 83/3 vascular event . Soccer is most popular in Argentina Government estimates are that 11 percent of the popu- and UK. lation cannot meet their basic food needs. Poverty rates

International Review of the Armed Forces Medical Service 68 Revue Internationale des Services de Santé des Forces Armées are about 20 percent higher in the rural areas than biscuits and cakes. They've been found to have the same they are in the urban areas. In the greater Buenos Aires effect on cholesterol levels as saturated fat and should be metropolitan area the poverty rate is 29.8 percent, avoided as much as possible. When reducing total fat, it's while in the subtropical jungle areas of the Northeast, important not to cut out the heart healthy fats from your the rate is 60 percent. The second-poorest area of the diet including mono and poly-unsaturated fats and country is the mountainous region of the Northwest omega-3, mostly found in plant and fish oils (eg sardines, where the poverty rate is 53.6 percent3. mackerel, fresh tuna, salmon). Certain plant-derived compounds, called stanol or sterol esters have been shown to Nearly 13 million people live in poverty in the UK that’s reduce cholesterol levels. Fruit and vegetables are rich in 1 in 5 of population. 3.8 million children in the UK are many essential nutrients including vitamins C and E and living in poverty. 2.2 million pensioners in the UK are carotenoids (which are all antioxidants). Diets Rich in living in poverty. 7.2 million working age adults in the wholegrain food can reduce the risk of CVD by up to UK are living in poverty. 70% of Bangladeshi children in 30 percent. A diet that includes at least 25 g of soya per the UK are poor. omen are the majority in the poorest day has been associated with reductions in LDL-choleste- groups. London has a higher proportion of people rol and CVD. Consuming moderate amounts of alcohol living in poverty than any other region in the UK. The between one and two units a day has been found to UK has a higher proportion of its population living in reduce the risk of CVD. Alcohol can increase HDL choles- relative poverty than most other EU countries: of the 27 terol and makes it less likely that clots will form. (British EU countries, only 6 have a higher rate than the UK78. Heart Foundation). Supplements combining folic acid and vitamins B6 and B12 did not reduce the risk of major SOCIAL DEPRIVATION cardiovascular events in patients with vascular disease98. AND CARDIOVASCULAR EVENTS A Group of European medical researchers have published Woodward et al in Scotland found that the social gra- a text that is an update of knowledge about the preven- dient in cardiovascular event rates was inadequately tion of cardiovascular disease and the rehabilitation of reflected by the Framingham score, leaving a large patients with such disease82. social disparity in future victims not identified as high risk. ASSIGN score (derived from cardiovascular out- IDENTIFYING PREMATURE CVD comes in the Scottish Heart Health Extended Cohort (SHHEC)) classified more people with social deprivation Dr. Stanley Franklin and colleagues at the UC Irvine Heart and positive family history as high risk, anticipated Disease Prevention Program in conjunction with resear- more of their events, and abolished this gradient111. chers at the Framingham Heart Study reviewed blood pressure data from 9,657 participants in the Framingham Researchers at Harvard University report that lack of Heart Study who had not received antihypertensive health insurance is taking a huge toll on US citizens and treatment and found that the combination of low dias- is associated with 45,000 excess deaths annually among tolic and high systolic numbers to be a superior predictor those aged 18 to 64 years, even after controlling for of future adverse cardiovascular events91. factors such as smoking, obesity, race and ethnicity, income, and alcohol use51, 52, 64. Among elderly people A low thigh circumference seems to be associated with hospitalization of a spouse is associated with an increa- an increased risk of developing heart disease or pre- sed risk of death, and the effect of the illness of a mature death. The adverse effects of small thighs spouse varies among diagnosis. Such interpersonal might be related to too little muscle mass in the region. health effects have clinical and policy implications for The measure of thigh circumference might be a rele- the care of patients and their families28. vant anthropometric measure to help general practitioners in early identification of individuals at an PREVENTION OF CVD increased risk of premature morbidity and mortality48. The provision of information and advice relating to cardiac rehabilitation must be better tailored to the context SCREENING CVD of the specific needs, beliefs, and circumstances of Professor Ian A. Scott of Princess Alexandra Hospital, 7, 33 patients with CHD, regardless of their ethnicity . Brisbane (Australia) has recently published a most inte- Potentially reversible factors that can be modified: over- resting article on Evaluating cardiovascular risk assess- weight, diabetes, smoking, high blood pressure, inacti- ment for asymptomatic people (BMJ 2009;338: a2844). vity, increased levels of LDL-cholesterol, high triglyce- According to the Scottish Health Survey Targeted scree- rides, low HDL-cholesterol, large waist circumference ning strategies are less costly than mass screening, and (being «apple shaped»). can identify up to 84% of high-risk individuals. The additional resources required for mass screening may Nutrition not be justified63. 16-MCT (16-row multidetector compu- Trans-fatty acids are a particular kind of fat that are natu- ted tomography) is a promising non-invasive diagnostic rally occurring in meat and dairy products but may also tool for the assessment of patients with coronary artery disease, useful for the detection and characterization of be produced when plant-based oils are hydrogenated to VOL. produce solid spreads, such as margarines. They're often the different types of plaques. (Carrascosa, Patricia. Rev. 83/3 found in confectionery and processed food like pastry, Argent. Cardiol. v.76 n.3 Buenos Aires mayo/jun. 2008).

International Review of the Armed Forces Medical Service 69 Revue Internationale des Services de Santé des Forces Armées NICE has launched public health guidance to reduce 12. Argentina: Chagas Disease - Science Progresses but premature death rates in disadvantaged areas, focusing Prevention Lags-Global Information Network-July 13, 2005. on proactive case-finding (NICE, 2008a). The guidance http://www.redorbit.com/news/health/173651/argen- recommends a number of ways, such as health session- tina_chagas_disease__science_progresses_but_preven- tion_lags/index.html. sin community venues, to identify disadvantaged people who are at high risk of cardiovascular disease and 13. Argentina-Poverty and wealth-Encyclopaedia of the Nations. other smoking-related diseases (New guidance aims to http://www.nationsencyclopedia.com/economies/Americas/Argen identify people at risk of early death. Nursing Times; tina-POVERTYAND-WEALTH.html. 104: 40, 21-22.) 14. ARIAS, Daniel. Descubren un mecanismo clave del mal de TREATMENTS AND COSTS OF CARING Chagas. La Nación-6 de septiembre de 2001.

Surgical treatments of CVD are: a) Percutaneous trans- 15. AUSTIN, Annie. Being grumpy can hurt your heart- luminal coronary angioplasty (PTCA) either balloon Negativity linked to heart disease -Suite 101- The genuine angioplasty or placing a stent (in some cases they incor- article library. porate drugs), b) Coronary artery bypass graft or CABG, c) Valve replacement, d) Cardiac pacemakers (including 16. BADALIANTS IE. Clinical therapeutic aspects of the origin and the course of atherosclerosis in the veterans of the CRT, cardiac resynchronisation) and e) Heart transplant. Great Patriotic War-Adv Gerontol. 2008;21(4):633-9. More recently robotic cardiac surgery is being done (Mohr FW et al. J Thorac Cardiovasc Surg 2001; 121: 17. BÄR, Nora. Prevención cardíaca cuanto antes mejor. La 842-53.) Nación-11 de agosto 2009.

In Argentina coronary surgery with extracorporeal 18. BARRET, Stephen. Risk Factors for Cardiovascular diseases. pump costs an average of $10.750 (Argentine pesos) Quackwatch. (Rubio, Miguel, Insúa, Jorge T. Rev. Argent. Cardiol. v.74 http://www.quackwatch.com/03HealthPromotion/cardiorisk.html n.4 Buenos Aires, jul./ago. 2006). The cost of caring for 19. BBC Health-What’s the right activity for me? June 2007. a survivor of CHD event is high these patients need a high level of post-event care, and beds in the intensive 10. BBC News-Crime down for third year running. Thursday, care and cardiac care units are generally considedred to 13 April 2006. be the most expensive in a hospital. Furthermore, there are the indirect costs associated with premature morta- 11. BBC News-Nottingham «UK burglary capital». 18 April lity and morbidity lost productivity, increased state 2006. dependence and cost of informal care. CVD costs the UK economy £29 billion a year in healthcare expendi- 12. BBC News-Nottingham and London residents most likely ture and lost productivity. (UK DH Department of to be burgled. Friday 14 August 2009. Health). 13. BLANE D. Social determinants of health -socioeconomic status, social class, and ethnicity. Am J Public Health The total direct health care cost of CAD in the UK in 1995;85: 903-905. 2001 was estimated to be approximately £1.8 billion. The largest cost components were drug treatment 14. Blood Pressure Association-Blood pressure news-UK High (70%) and hospital treatment (25%). Friction-adjusted blood pressure rises but diagnoses increase master- 26/1/09. indirect costs of CAD borne by society in the UK are estimated to be £702 million, or approximately 28% of 15. BOISSONET, Carlos. Rev. Argent. Cardiol. v.76 n.5. Ciudad the overall costs of CAD. (Arran Shearer et al - Br J Autónoma de Buenos Aires, Sept-Oct 2008. Cardiol. 2004;11(3), 2004 ) 16. British Heart Foundation Statistics Website-Better esti- SUMMARY mates of mortality from diabetes. http://www. hearts- tats.org/datapage.asp?id=1113. Twenty-seven years ago Argentine and British forces collided in what was considered Great Britain’s last 17. British Heart Foundation-Get active ! colonial war77, 99. Combatants of both sides face now a http://www.bhf.org.uk/keeping_your_heart_healthy/staying_ common foe: Cardiovascular diseases (CVD) which will active.aspx. become more evidente as the years go by. Argentina 18. British Hypertension Society. www.bhsoc.org/pdfs/hit.pd. and United Kingdom have great similarities regarding coronary Risk Factors (RF). The late psychological 19. British Nutrition Foundation-Salt in the diet. effects of the 1982 conflict are linked to CVDs. The psy- http://www.nutrition.org.uk/home.asp?siteId=43§ionId= chological effects may even trigger acute cardiac 780&parentSection=341&which. events. 20. Chagas disease : a neglected emergency. The Lancet, BIBLIOGRAPHY Volume 373, Issue 9678, Page 1820, 30 May 2009.

VOL. 11. American Heart Association-Risk factors and coronary 21. Chagas News The fight against Chagas: time to focus th 83/3 heart disease and strokehttp:// www. american- on patients July 9 , 2009. http://chagas-rompe-el- heart.org/presenter.jhtml?identifier=539. silencio.com/news_art0003.html.

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26. Consumen más alcohol otros países. La Nación, 20 de 45. GRANT, B.F. and DAWSON, D.A. Age at onset of alcohol Octubre de 2009. use and its association with DSM–IV alcohol abuse and dependence: Results from the National Longitudinal 27. Contaminación de aire en la Argentina. Alcohol Epidemiologic Survey. Journal of Substance Abuse http:// www.geocities.com/RainForest/2713/cairargs.htm. 9: 103–110, 1997. PMID: 9854701.

28. CHRISTAKIS, Nicholas and ALLISON, Paul. Mortality after 46. Gulf War and health: Volume 6-Physiolohic, Psychologic the hospitalization of a spouse. The New England Journal and Psychosocial effects of deployment related stress. The of Medicine. 2006;354: 719-30. National Academies Press. Committee on Gulf War and Health. 29. CRUCES, Guillermo and WODON, Quentin. Riskj-Adjusted poverty in Argentina:Measurement and determinants- 47. Hallan Chagas en momias de 9000 años. La Nación, 8 de Discussion Paper-N. DARP 72, September 2003. febrero de 2004.

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38. Estadisticas del consumo de alcohol en Argentina. 54. JONES, Gareth H. and LOVETT, Jonathan W. T. Delayed psy- http://html.rincondelvago.com/estadisticas-del-consumo- chiatric sequelae among Falklands veterans. Royal College de-alcohol-en-argentina.html. of General Practitioners-1987 January;37(294):34-35.

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VOL. 83/3

International Review of the Armed Forces Medical Service 73 Revue Internationale des Services de Santé des Forces Armées INSTRUCTIONS TO AUTHORS RECOMMANDATIONS AUX AUTEURS

• All material intended for publication in the International Review of • Tout travail destiné à la publication dans la Revue Internationale des the Armed Forces Medical Services (IRAFMS) should be submitted to the Services de Santé des Forces Armées (RISSFA) doit être envoyé au Editor’s office : Bureau de la rédaction :

International Committee of Military Medicine Comité International de Médecine Militaire Hôpital Militaire Reine Astrid Hôpital Militaire Reine Astrid BE - 1120 Brussels, Belgium. BE - 1120 Bruxelles (Belgique)

• Scientific articles, analyses or reviews of books and articles related to • Sont pris en considération les articles scientifiques, les analyses d’ou- military medicine, symposia or congress proceedings, scientific events vrages ou d’articles médico-militaires, les comptes rendus de réunions, and announcements written in French, English or Spanish will be congrès, événements scientifiques et les annonces, rédigés en français, considered. anglais ou espagnol. • Full name(s), address (es), short curriculum vitæ and photograph(s) of • Tous ces travaux doivent être accompagnés des noms, adresse, bref the author(s) should accompany each contribution. curriculum vitæ et photo du (ou des) auteurs(s). Ceux-ci reconnaissent • The authors implicitely recognize that the proposed documents have implicitement que le document proposé n’a pas été envoyé en même not been sent simultaneously to other journals or have not been temps à d’autres revues ou qu’il n’a pas été publié récemment sous le recently published under the same title. même titre. • The Editor of the IRAFMS may require authors to justify the assi- • La Direction de la RISSFA se réserve le droit, dans certain cas, de gnment of authorship. demander au signataire d’un écrit la justification de sa qualité d’auteur. • Toute reproduction partielle ou totale d’un article paru dans la RISSFA • All partial or complete reproductions of an article which has been est soumise à l’accord préalable de l’Éditeur de cette dernière. published in the IRAFMS are submitted to the previous agreement of the Editor of the IRAFMS. • Le manuscrit sera dactylographié en double interligne, marge gauche de 3 cm, 35 lignes par page, sur le recto seulement et n’excédera pas 25 pages, • Manuscripts should be typewritten on one side only, double-spaced références bibliographiques comprises. Il sera envoyé format A4 (Word, throughout, with a 3 cm margin at the left hand side and a maximum Arial 12), soit par e-mail à l’adresse suivante : [email protected] ou of 35 lines. The text should not exceed 25 typewritten pages, including par voie postale sur CD-Rom accompagné d’une epreuve papier. bibliographic references. It should be submitted on A4 paper (Word format Arial 12) via e-mail to [email protected] or via postal ser- • Le résumé de l’article rédigé en français et anglais (espagnol ad libitum) vice on CD-Rom with a printing proof. ne dépassera pas 150 mots, et sera accompagné de la traduction du titre dans ces deux langues. • A summary of no more than 150 words should be include. It would be • Il est indispensable de fournir 3 à 5 mots-clés en anglais et en français desirable to submit the summary in both French and English (Spanish ad afin de faciliter l’indexation de l’article. libitum). • Les abréviations doivent être évitées dans le texte, sauf celles se rap- • Three to five keywords should be provided in order to assist indexers portant aux unités scientifiques de mesure, dûment acceptées (unités in cross-indexing the article. SI). Si d’autres abréviations sont utilisées, elles doivent être précédées • Abbreviations should be avoided in the text except for accepted scientific de la terminologie complète à laquelle elles se rapportent, lorsqu’elles units of measurements (SI units). Other abbreviations, if used, should be sont mentionnées dans le texte pour la première fois. spelt out in full when first mentioned in the text. • Les auteurs sont invités à inclure, dans l’envoi de leur manuscrit, les • When sending their manuscripts, the authors are invited to include tableaux, graphiques, photos et illustrations indispensables accom- the necessary tables and illustrations. Drawings and legends should be pagnés de leurs légendes. Les dessins et légendes, soigneusement exé- carefully printed so as to be directly reproduced. Each illustration cutés, devront pouvoir être reproduits directement. Chaque figure sera should be identified by writing a figure number or a short mention on identifiée par une mention permettant de l’inclure correctement dans the back. le texte. • References should be numbered in the order in which they appear in • Les références seront inscrites dans l’ordre dans lequel elles paraissent the text and referred to by Arabic numerals in brackets. They are listed dans le texte et indiquées par des chiffres arabes, entre parenthèses. as follows : Elles seront mentionnées comme suit : 1. For a journal : author’s name and initials, full title of the article (in the 1. Pour un périodique : nom et initiales des prénoms de tous les auteurs, original language), title of the journal, year of publication, volume titre de l’article (dans la langue originale), nom du périodique, année, number, first and last page numbers. volume, page initiale et page finale de l’article. 2. For a book : author’s name and initials, title of the book, name of 2. Pour un livre : nom et initiales des prénoms du ou des auteurs, titre the publisher and city, year of publication, pages corresponding to the du livre, nom de la maison d’édition, ville et année de publication, quotation. pages correspondant à la citation.

ADDRESS FOR SUBSCRIPTION ADRESSE POUR LES ABONNEMENTS SUBSCRIPTIONS 2010 ABONNEMENTS 2010 International Review of the Armed Forces Medical Services Revue Internationale des Services de Santé des Forces Armées N.E.P. N.E.P. 13, rue Portefoin - FR-75003 Paris, France 13, rue Portefoin - FR-75003 Paris (France) Tel : +33 (0)1 40 27 88 88 - Fax : +33 (0)1 40 27 89 43 Tel : +33 (0)1 40 27 88 88 - Fax : +33 (0)1 40 27 89 43 E-mail : nep@wanadoo. fr E-mail : nep@wanadoo. fr Credit Lyonnais : 7828 H - Paris Haxo (N.E.P.) Crédit Lyonnais : 7828 H - Paris Haxo (N.E.P.) Subscription for one year : € 60 Abonnement pour 1 an : € 60 Cost for a single copy : € 20 Prix du numéro ordinaire : € 20

I.S.S.N. : 0259-8582 Imprimerie Chauveheid, Stavelot (Belgique) VOL. 83/3

International Review of the Armed Forces Medical Services 74 Revue Internationale des Services de Santé des Forces Armées ad.L.e.A4.fhmx 02.06.2006 11:52 Uhr Seite 1

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Probedruck Powder for solution for infusion Treatment of known or suspected cyanide - 03/2009

STORM poisoning

CYANOKIT® 2,5 g powder for solution for infusion. PHARMACEUTICAL FORM: Dark red crystalline powder for solution for infusion (IV): 2 vials (each one contains 2.5 g powder) + 2 sterile transfer devices + 1 sterile intravenous infusion set + 1 sterile short catheter for administration to children. COMPOSITION*: After reconstitution with 100 ml of diluent, each ml of the reconstituted solution contains 25 mg of hydroxocobalamin. INDICATIONS: Treatment of known or suspected cyanide poisoning. Cyanokit® is to be administered together with appropriate decontamination and supportive measures. POSOLOGY AND METHOD OF ADMINISTRATION*: Initial dose: Cyanokit® is administered as an intravenous infusion over 15 min. Adults: the initial dose of Cyanokit® is 5 g. Paediatric patients: the initial dose is 70 mg/kg body weight not exceeding 5 g. Subsequent dose: Depending upon the sevirity of the poisoning and the clinical response, a Body weight in kg 5 10 20 30 40 50 60 second dose may be administered by intravenous infusion.The rate of infusion for the second Initial dose dose ranges from 15 minutes to 2 hours based on patient condition. Adults: 5 g. Paediatric in g 0.35 0.70 1.40 2.10 2.80 3.50 4.20 patients: 70 mg/kg body weight not exceeding 5 g. Maximum dose: Adults: 10 g. Paediatric in ml 14 28 56 84 112 140 168 patients: 140 mg/kg not exceeding 10 g. Renal and hepatic impairments: Cyanokit® is administered as emergency therapy in an acute, life threatening situation only and no dosage adjustment is required in these patients. CONTRAINDICATIONS: None. SPECIAL WARNINGS AND PRECAUTIONS FOR USE*: Treatement of cyanide poisoning must include immediate attention to airway patency, adequacy of oxygenation and hydration, cardiovascular support, and management of seizures. Treatment decisions must be made on the basis of clinical history and/or signs and symptoms of cyanide intoxication. - Smoke inhalation: Before Cyanokit® is administered, it is recommended to check affected persons for the presence of exposure to fire smoke in an enclosed area, soot present around mouth, nose and/or oropharynx, altered mental status. Hypotension and/or a plasma lactate concentration ≥ 10 mmol/l are highly suggestive of cyanide poisoning. In the presence of the above signs, treatment with Cyanokit® must not be delayed to obtain a plasma lactate concentration. - Known hypersensitivity to hydroxocobalamin or vitamin B12 must be taken into benefit-risk consideration before administration of Cyanokit®. - Transient, generally asymptomatic, increase in blood pressure may occur with a maximal increase toward the end of infusion. - Effects on blood cyanide assay. Recommended to draw the blood sample before intiation of treatment with Cyanokit®. - Interference with burn assessment due to a red colouration of the skin. However skin lesions, oedema, and pain are highly suggestive of burns. - Interference with laboratory tests (e. g. clinical chemistry, haematology, coagulation and urine parameters) because of hydroxocobalamin‘s deep red colour. Caution is required when reporting and interpreting laboratory results. - Use with other cyanide antidotes: has not been established; they must not be administered concurrently in the same intravenous line. INTERACTIONS* PREGNANCY AND LACTATION*: There are no adequate data from the use of hydroxocobalamin in pregnant women and the potential risk for humans is unknown. However, taken into account that no more than two injections of hydroxocobalamin are to be administered, the potentially life threatening condition, the lack of alternative treatment, hydroxocobalamin may be given to a pregnant woman. Health care professionals are requested to promptly report the exposure during pregnancy to the Market Authorisation Holder and to carefully follow-up on the pregnancy and its outcome. Because hydroxocobalamin will be administered in potentially life-threatening situations, breast-feeding is not a contraindication. UNDESIRABLE EFFECTS*: The most frequents: reversible red colouration of the skin and mucous membranes, marked dark red colouration of the urine. Reported in association with Cyanokit® use, without frequency estimations: artificial elevation or reduction in the levels of certain laboratory parameters; ventricular extrasystoles; decrease in the percentage of lymphocytes; memory impairment, dizziness; eye disorders such as swelling, irritation, redness; pleural effusion, dyspnoea, throat tightness, dry throat, chest discomfort; abdominal discomfort, dyspepsia, diarrhoea, vomiting, nausea, dysphagia; pustular rashes (face and neck); transient increase in blood pressure; hot flush; headache, injection site reaction, peripheral oedema; allergic reactions including angioneurotic oedema, skin eruption, urticaria and pruritus; restlessness. OVERDOSE*: Treatment is directed to the management of symptoms. PHARMACODYNAMIC PROPERTIES*: Antidote, ATC code: V03AB33. Mechanism of action: Each hydroxocobalamin molecule can bind one cyanide ion by substituting the hydroxo ligand linked to the trivalent cobalt ion to form cyanocobalamin, a stable, non-toxic compound that is excreted in the urine. PHARMACOKINETIC PROPERTIES*. PRECLINICAL SAFETY DATA*. INCOMPATIBILITIES*: Cyanokit® must not be mixed with other medicinal products except the recommended diluant - No simultaneous administration of hydroxocobalamin through the same intravenous line with the following drugs: diazepam, dobutamine, dopamine, fentanyl, nitroglycerine, pentobarbital, phenytoin sodium, propofol and thiopental, sodium thiosulfate, sodium nitrite and ascorbic acid. - Simultaneous administration of hydroxocobalamin and blood products through the same intravenous line is not recommended. SPECAIL PRECAUTIONS FOR STORAGE*: Do not store above 25°C. The reconstituted solution has to be used immediately. SPECIAL PRECAUTIONS FOR DISPOSAL AND OTHER HANDLING*: Each vial is to be reconstituted with 100 ml of diluent (sodium chloride 9 mg/ml (0,9 %) solution for injection) using the supplied sterile transfer device. The intravenous infusion set provided in the kit must then be used. MARKETING AUTHORISATION HOLDER: Merck Santé s.a.s., Lyon, France. MARKETING AUTHORISATION NUMBER: EU/1/07/420/001. * For more details please refer to SmPC on the EMEA website.

Merck Serono Emergency Care