Preparation for Medevac

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Preparation for MedEvac

CONTENT

1 Content 2 Editorial Ch. Büttner 69 Business Mirror 71 Upcoming Events 72 Imprint

NATO CENTRE OF EXCELLENCE FOR MILITARY MEDICINE

39 NATO Centre of Excellence for Military Medicine K. A. Ferland p. 4 (MILMED COE)

CHALLENGES IN MILITARY MEDICINE – LESSONS LEARNED, TRAINING, EXERCISES 22 Clinical and Epidemiological Assessment A. Panariti, L. Nikollari, in Visceral Leishmaniasis M. Duli 58 Amputations in Patients Admitted H.M. H. Tayseir, with Diabetic Septic Foot M. el M. Osman, A.A.M. Hassan 64 Epidemiological Profile of Trauma at the L. Nikollari, E. Nikollari University Hospital Trauma & Military Hospital p. 48 in Tirana, Albania

CHALLENGES IN MILITARY MEDICINE – NEW DEVELOPMENTS 28 Serving the Services for more than 100 Years Ch. Büttner 42 Effects of a New Piezoelectric Device on Local M. Stoetzer Microcirculation and the Periosteum-Bone Interface after Subperiosteal Preparation

UROLOGY SPECIAL

32 Management of Urethral Injuries D. Liebchen p. 68 in Foreign Assignments 35 Management of Genital Injuries A. Martinschek, M. Höppner, – from Trauma to Reconstruction C. Sparwasser Index of Advertising

ORGANISATION OF MEDICAL SUPPORT AND EXPERIENCES IN OPERATIONAL MEDICINE Atmos ...... 45 4 Long-Distance Mass Body Repatriation T.J. Lighthelm, J. Louw, rd from an Ebola-Risk Area J.T. Claassen Dräger ...... 3 Cover 10 Mass Casualty Aero-Medical Evacuation T.J. Lighthelm, L.A. Wallis, S. Martin, P.J. van Aswegen Karl Storz...... 13 18 Military Medical Support in the Humanitarian Arena (MMSHA) J. Meyer, J. Koch, O. Krieter Maquet...... 27 40 Canadian Armed Forces Medical Risk Matrix C.H.T. Cross MediHelp ...... 63 48 Quality Increase of Emergency Health Care S. Goncharov, O. Garmash to the Injured Philips ...... 21 50 11 Years of Air Quality Monitoring in Afghanistan J. D. Lalonde, M. Bradley Schiller...... 55 CONFERENCES/CONGRESSES Schülke & Mayr...... 25 56 International DiMiMED Confronts Current Questions on the Cooperation of Civilian and Military Facilities Siemens ...... 3

REPORTS Takeda ...... 7 68 43rd COMEDS Plenary Session in Berlin Water-Jel ...... 33

Zeppelin...... 61

ZOLL ...... 4th Cover

Source: South African National Defence Force (SANDF). 1 EDITORIAL

Dear Reader

Your tremendous feedback demonstrates medical services in this context as well as on that, as well as organisational issues, articles the resulting successful cooperation world- covering deployment-specific issues are of wide. particular interest. So I would like to specifically invite you to This exchange of knowledge and experience write about your experiences in this field. ultimately benefits the patients we look after. So we are very much looking forward to con- Finally, let me remind you about the Confer- tinuing to publish your very varied and in ence on Disaster and Military Medicine, which some cases very specific experiences. is being held at MEDICA on the 17th to the 18th of November 2015 in Düsseldorf, Military missions involving the medical Germany. services are currently on the rise. The emerging global refugee problem is one of I am sure that the presentations and work- grave concern. It presents a major challenge shops we have prepared will be of great inter- to the medical services and aid organisations. est to all attendees. As Editor in Chief, I feel particular satisfaction Dr Christoph Büttner to be able to report on the excellent medical I would be delighted to welcome many loyal Rear Admiral uh (ret) MC and humanitarian achievements of the readers of our magazine to the event. Editor-in-Chief MCIF

亲爱的读者： Chers lecteurs, Уважаемый читатель, Estimados lectores: Vos nombreux retours montrent qu’en Судя по многочисленным отзывам, Sus numerosos comentarios indican 根据众多读者的反馈显示，除了组织话题 plus des questions organisationnelles les кроме организационных тем, особый que además de los temas organizativos, 以外，关于特定专题的文章也是备受关注 articles sur les questions techniques spé- интерес для наших читателей также también resultan particularmente inte- 。 cifiques aux interventions vous представляют статьи о конкретных тех- resantes artículos sobre temas especia- intéressent au plus haut point. нических вопросах. lizados específicos de la práctica. 知识经验的交流最终会让受关注的病患受 Такой обмен знаниями и опытом, в Cet échange de connaissances et d’ex- Este intercambio de conocimientos y 益。所以我们很高兴将来能发表您与众不 конечном счете, позитивно скажется на périences est à terme bénéfique pour les experiencias beneficia, al fin y al cabo, 同的部分专业经验。 лечении пациентов. Поэтому мы с patients. Nous publierons donc à l’avenir a los pacientes que deben atenderse. удовольствием будем продолжать Por esta razón, nos complacerá publi- 目前，军事公共卫生服务再次得到完善。 vos expériences, très différentes et en публикации описываемых вами car también en el futuro sus experien- 我最大的担忧就是出现的国际难民问题。 partie très spécifiques. очень разных, а иногда и очень спе- cias completamente diferentes entre sí 这为公共卫生和慈善机构带来巨大挑战。 Actuellement, les missions militaires des цифических практических ситуаций в y, en parte, muy específicas. 作为主编，我特别报道了与公共卫生和慈 services sanitaires se multiplient. Je будущем. 善机构相关的医疗和人道主义方面的突出 regarde également avec une grande В настоящее время медико-санитар- Actualmente aumentan una vez más 成果以及由此达成的成功合作。 inquiétude la problématique mondiale des ным службам вновь приходится прини- las misiones militares de los servicios réfugiés. C’est pour les services sani- мать участие в военных миссиях. Глу- médicos. Con gran preocupación 因此，我诚挚邀请您撰写相关的经验报告 taires et les organisations d’aide un autre бокую озабоченность также вызывает observo también la problemática mun- 。 défi majeur. Il est de mon devoir en tant растущая глобальная проблема бежен- dial de los refugiados que se perfila. que rédacteur en chef de rendre compte цев. Это является еще одним серьез- Esta configura otro gran desafío para 最后，请您再次关注灾难和军事医疗会议 des prestations médicales et humani- ным вызовом для медико-санитарных los servicios médicos y las organizacio- ，MEDICA医疗展将于2015年11月17-18 taires exceptionnelles des services sani- служб и организаций по оказанию nes de ayuda. En carácter de redactor помощи. Будучи главным редактором 日在德国杜塞尔多夫举行。 taires et des organisations d’aide et des jefe, es para mí una cuestión especial объектом моего особого внимания coopérations fructueuses qui en informar acerca de las sobresalientes является освещение первостепенных 我相信，您将对我们从参与者中挑选出的 prestaciones médicas y humanitarias découlent. медицинских и гуманитарных задач 演讲和专题讲座产生极大兴趣。 de los servicios médicos y de las orga- Je vous invite donc fortement à nous faire медико-санитарных служб и гуманитар- nizaciones de ayuda, y las exitosas coo- part de vos expériences par écrit. ных организаций, а также успешного их 我谨以个人名义向我们杂志的众多忠实读 сотрудничества в выполнении этих peraciones vinculadas con ellas. Enfin, je me permets d’attirer une nou- 者表示真挚问候。 задач. En consecuencia, los invito enfática- velle fois votre attention sur la "Confer- mente a escribir los correspondientes ence on Disaster and Military Medicine" Поэтому я убедительно прошу вас писать нам о вашем опыте и мнениях informes de experiencias. qui aura lieu durant le salon MEDICA du по этим вопросам. 17 au 18 novembre 2015 à Düsseldorf, Por último, quisiera permitirme una vez en Allemagne. Наконец, я хотел бы воспользоваться más por propio interés, la referencia a возможностью и вновь обратить ваше la Conference on Disaster and Military Je suis sûr que les conférences et ate- внимание на предстоящую конферен- Medicine, que tendrá lugar durante la liers sélectionnés susciteront un grand цию по медицине катастроф и военной MEDICA del 17 al 18 de noviembre de intérêt auprès de nos participants. медицине, которая будет проходить во 2015, en Düsseldorf, Alemania. Je serais très heureux d’accueillir person- время выставки MEDICA в Дюссель- Estoy seguro de que las conferencias y nellement les nombreux et fidèles дорфе, Германии, 17-18 ноября 2015 года. los talleres seleccionados serán de gran lecteurs de notre magazine. interés para nuestros participantes. Я уверен в том, что выбранные лекции и семинары вызовут огромный интерес Me agradaría poder saludar personal- среди участников конференции. mente a muchos fieles lectores de Я был бы очень рад приветствовать nuestra revista. наших многочисленных постоянных читателей среди участников конферен- ции.

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Answers for life. MASS BODY REPATRIATION

T. LIGTHELM, J. LOUW, J.T.CLAASSEN (SOUTH AFRICA) Long-Distance Mass Body Repatriation from an Ebola-Risk Area This paper discusses the organisation approach to a mass body repatriation from Nigeria to South Africa during the Ebola outbreak in Nigeria. A complete different approach was followed by flying in refrigeration mass body repatriation trucks and support vehicles by cargo plane to collect the bodies from various mortuaries within the city. These trucks, with the bodies were then driven back into the plane and flown back. During the operation, all precautions for possible Ebola Virus Disease were implemented.

Introduction nn Ikeja Mortuary: 7 Bodies- 5 km from the air- limited infrastructure and political turmoil A case of Ebola Virus Disease was introduced port. back to South Africa, over a distance of into Nigeria on 20 July 2014 when an infected nn Yaba Mortuary: 63 Bodies- 9 km from the 4500 km. Liberian man arrived by aeroplane into Lagos, airport. Africa's most populous city. The man, who nn Isolo Mortuary: 46 Bodies- 15 km from the Discussion died in hospital 5 days later, set off a chain of airport. Ebola Risk transmission that infected a total of 19 peo- These facilities had a non-reliable and often Believers from all over Africa travel to this ple, of whom 7 died(1). Nigeria was only disrupted electricity supply, with limited body SCOAN church, due to the claims and rituals declared Ebola-free on 20 October 2014(2). storage space, resulting in bodies in various of alleged healing which are widely publicized On Friday, 12 September 2014 at approxi- stages of decomposition, stacked together in (3). Numerous allegations and non-substanti- mately 12:44 local time (3) a guesthouse, non-ideal storage facilities. The standard of ated statements were made at the time that located within the Synagogue Church of All storage in these mortuaries varied from poor the pastor of this church, T.B. Joshua, had Nations (SCOAN) premises in Lagos, Nigeria to very good. claimed to be able to cure Ebola Virus Disease collapsed. This resulted in the largest number Post mortem examinations were conducted by and able to “wash off Ebola” from people of South African citizens killed in a single the Nigerian authorities, with causes of death exposed to the disease. As the nationality of event on a single day since World War II. 81 indicated as shown in Table 1. the non-South African victims were unknown South African citizens and 4 persons travel- at the time, it was possible that Ebola ling with South African travel documents were Causes of Death Number (n84) patients from Sierra Leone, Guinea or Liberia, among the 116 people killed in this event(4). Asphyxia 23 where the Ebola outbreak occurred or from The average age of the deceased was 43, 4 Multiple Injuries 36 Nigeria itself, may have taken a pilgrimage to years with 36 males and 48 female (n 84). The the church. These allegations, which could Exsanguinations 14 30 unknown bodies were of unidentified neither be substantiated nor proven false, nationality and may also have been South Head Injury 4 was holding the risk that some of the victims African (later proven not to be South African). Chest Injury 5 killed in the event, may have been suffering An undeclared number were injured, amongst No record available 2 from Ebola Virus Disease. As bodies were them 26 South Africans. The bodies and those transported and stored in close proximity with injured were trapped together underneath the Tab. 1: Causes of Death other bodies from the city where an outbreak building rubble for an extended period before occurred, the risk was that the decomposing all injured and bodies were recovered from Problem Statement South African bodies were contaminated with the site. To repatriate up to 115 bodies in non-ideal body fluid from Ebola Virus Disease patients. The bodies were evacuated from the site by condition, possibly contaminated with body The deceased could also have been suffering the Nigerian authorities to three mortuaries fluids from Ebola Virus patients, from a highly from other communicable diseases such as spread around Lagos: populated and congested city, with very extreme-drug resistant Tuberculosis, as many

本文讨论了在尼日利亚埃博拉疫情期间， Cet article traitE l'approche de l'organisa- В этой статье речь идет об организа- Este artículo habla sobre el enfoque 将尸体从尼日利亚大量遣返至南非的组织 tion d'un rapatriement en masse de corps ционном подходе к массовой репат- organizativo a una repatriación masiva риации тел из Нигерии в Южную 方法。这次大量遣返尸体行动采用了完全 du Nigeria vers l'Afrique du Sud lors du de cuerpos de Nigeria a Sudáfrica Африку во время вспышки лихорадки durante la epidemia de ébola en Nige- 不同的方法，首先用货运飞机将冷藏车和 déclenchement d'Ebola au Nigeria. Une Эбола в Нигерии. В этом случае был 支援车辆运至目的地，这些车辆前往市内 procédure complètement différente a été предложен совершенно новый подход, ria. Se siguió un método completa- 各太平间接收尸体。再将这些装载了尸体 adoptée, consistant à amener sur place, который заключался в том, что грузо- mente diferente mediante el vuelo en 的卡车用飞机运回。在操作过程中，对可 par avion-cargo, des camions de rapatrie- вики-рефрижераторы и машины обес- camiones de repatriación masiva de 能的埃博拉病毒病采取了所有的预防措施 ment réfrigérés ainsi que les véhicules de печения для массовой репатриации cuerpos y vehículos de apoyo en avio- 。 soutien pour recueillir les corps dans les тел были отправлены по воздуху на nes de carga para recoger los cuerpos грузовом самолете, чтобы собрать de distintas morgues de la ciudad. A différentes morgues de la ville. Ces трупы из различных моргов города. continuación, se llevaron estos camio- camions contenant les corps ont ensuite Эти грузовики, с телами погибших été rechargés dans l'avion et renvoyés. людей затем были привезены обратно nes con los cuerpos de regreso al avión Lors de cette opération, toutes les précau- в самолет, на котором была проведена para el vuelo de regreso. Durante la tions possibles pour éviter la Propagation дальнейшая репатриация по воздуху. operación, se implementaron todas las du Virus Ebola ont été mises en place. В ходе операции были приняты все medidas de precaución para la enfer- меры предосторожности для профи- medad del virus del ébola. лактики заражения лихорадкой Эбола.

4 MCIF 3/2015 desperate patients undertook a pilgrimage to possibility that more of the unidentified bod- the church for healing. ies may have been South Africans or citizens Ebola Virus Disease is caused by a virus from of the neighbouring countries). the family Filoviridae. Human-to-human trans- A Reconnaissance Team was deployed to mission occurs through contact with the body Lagos from 7-10 October 2014 to assess all fluid from an infected patient. This transmis- facilities, assess the condition of the bodies sion is well described, with an incubation and obtain principle approval from the Niger- period of 21 days (1). However, the duration ian Authorities. All facilities were visited and of the virus’s life cycle in a decomposing body all roads travelled at the proposed times, to is not well researched, especially in high and determine travel times. It was concluded that humid environmental temperatures and non- the full repatriation process will need to be ideal storage conditions. self-sustained with own capabilities and lim- The mortuary infrastructure of Lagos is very ited local support capabilities. limited, with very limited body transport capa- This reconnaissance resulted in a planned bilities, limited space in dilapidated mortuary Mass Body Repatriation Operation. Due to buildings, chaotic travel conditions and an bureaucratic challenges, traffic situation, unreliable power grid. This resulted in a chal- deteriorating condition of the bodies, political lenge to the South African military and civilian turmoil, distance and the number of bodies, it health authorities to identify and then repatri- was decided that the best solution will be a ate a minimum of 85 decomposing bodies, massive single day operation to, preferably, possibly contaminated with body fluids from repatriate all bodies in one operation. Fig. 1: Mass Body Repatriation Truck’s internal Ebola Virus Disease victims, over a distance Due to the nature of the operation, a joint mil- outlay of nearly 4500 km to South Africa. itary and civilian operation was planned, com- Due to the risk involved, the principle deci- bining the command and control, operational sion was taken to manage all bodies as possi- planning and decontamination skills of the drivers obtained International Driving Permits bly Ebola contaminated and to protect all staff South African Military Health Service with the prior to the deployment. Authority was members through high risk bio-safety precau- forensic pathology skills of the civilian Foren- obtained to import and export vehicles and tions(5). sic Pathology Service of the Department of equipment through the customs authorities. Health. This was supported by specialists Management of valuables and personal pos- Transport Challenges from the SA Police Service. Both civilian and sessions of the deceased were planned for. The number of bodies, condition of the bodies military Environmental Health staff were and the bio-safety risk ruled out the use of utilised, with military psychologists and Command and Control commercial repatriation and a decision was medico-legal staff as support elements. A military commander with a civilian co-com- taken to launch a joint military-civilian opera- Due to transport challenges in Lagos a plan mander was appointed and approved by all tion to repatriate the bodies to South Africa. was compiled to deploy mass body repatria- staff contributing institutions. These com- Although considered, the possibility of cremation trucks with cooling capabilities by cargo manders were given mission command flexi- tion was ruled out due to very limited facilities plane to Lagos. Support vehicles, also trans- bility during the operation. Functional control in Lagos and that the practice would not be ported with the cargo plane, would then aid was executed by each specialist grouping, be accepted by the families due to cultural prac- these trucks. Each support vehicle contained it military or civilian, over the specialist func- tices in South Africa. air-conditioned inflatable tents, trestles, per- tion answering to the joint command struc- No mass body transport capabilities were sonal protective equipment (PPE), decontami- ture. This command affiliation was described available in Lagos. Bodies are normally trans- nation equipment and body bags in order to in the pre-deployment formal plan and ported wrapped in a shroud by private under- establish a body preparation station at each approved by the Director-General of the takers in small sedan vehicles. Limited num- mortuary. Teams of civilian and military expert Department of Health and the Surgeon Gen- bers of these vehicles were available. personnel would be deployed to each mortu- eral. Limited space was available at the mortuaries ary consisting of a command element, foren- A command network utilising the local cellular to prepare bodies for repatriation while taking sic pathology officers; military emergency phone network was planned. the bio-safety procedures into account. care personnel trained in decontamination; Due to the limited transport capabilities, dete- environmental health officers; psychologists Body Identification riorating conditions of the bodies and bio- to initiate debriefing of staff; technical per- A Body Identification Team consisting of iden- safety risks, a decision was taken to deploy a sonnel and a medico-legal consultant. tification experts from the South African fully self-sustained capability team able to Police Service and initially also Forensic receive, prepare, decontaminate, cool, trans- A detailed flow-chart, linked to timelines, was Pathology and Forensic Dentistry experts were port and repatriate the bodies back to South compiled for the entire plan and specific deployed to Lagos. The team envisaged to Africa in a respectful manner. report lines were identified. This assisted in obtain fingerprints from the deceased for planning the inter-relationships with contrac- comparison to South Africa’s national finger- Planned Solution tors and suppliers to coordinate actions. Bag- print data bank, obtain dental records for In order to address the unique challenges, a ging channels were planned and the size of dental identification where fingerprints failed, combined civil-military plan was compiled to the team and number of channels were and to collect DNA samples. Due to Nigerian repatriate up to 115 bodies to South Africa in planned based on the number of bodies at authorities’ decisions, this team was only a combined transport and repatriation opera- each mortuary facility. allowed to participate partially in identification (the number was unconfirmed at this Special authority was obtained through a tion processes. The local authorities decided stage but minimum 85 South Africans was Note Verbale to the Nigerian Government to to only utilise DNA identification and to out- reported missing, assumed dead, with the drive South African vehicles in the country. All source the DNA matching function to a private

MCIF 3/2015 5 the mortuary facilities. The convoys departed from the airport at 04:20 Nigerian time and arrived at the mortuaries at 05:34. Each of the three teams’ disaster vehicle drivers received a personal satellite-tracking device through which the movements and locations of the teams could be monitored from within Nigeria and South Africa by command structures. To the benefit of the repatriation team, the 7 bodies at Ikeja mortuary were transferred the day before to Yaba mortuary and the team members allocated to Ikeja mortuary could be moved to Yaba where the majority of bodies (63) were located to increase the manpower and capacity. According to the flow-chart plan, reporting took place at specific pre-determined reporting timelines to ensure coordination. At each mortuary a Preparation Station was Fig. 2: Forensic Pathology Mass Body Transport Trucks and support vehicles positioned in Cargo set up and these tents were cooled down with Aircraft mobile air-condition units and generators to an average temperature of 22°C. The tents laboratory. (This process delayed the repatria- Service team to manage personal posses- had an entrance that was positioned in prox- tion to a 6-month operation and forced a sec- sions and valuables were deployed in imity to the exit of the mortuary and an exit ond wave repatriation operation). advance. where the mass body repatriation truck was The team arrived on 14 November 2014 at positioned. The trucks were pre-cooled en Execution 01:30 Nigerian time after a flight of 6 hours at route to the mortuaries and maintained an As soon as the Nigerian authorities agreed to the Military Section of Lagos International Air- average temperature of 10°C for the full day. the DNA identification of the majority of bod- port. Following custom procedures, the team After all of the bodies were successfully trans- ies a Mass Body Repatriation Capability, with was issued with their PPE equipment. Sizes of ferred to the truck and the load box doors staff, was deployed to Lagos. An Antonov 124 PPE were already determined in South Africa closed, the temperatures dropped to 2.5˚C. was chartered, transporting 4 Mass Body during one of the briefing sessions, which Repatriation Trucks with a combined capacity made it easy to distribute PPE correctly in All Preparation Stations were set-up in a to transport 85 bodies and 4 Light Delivery terms of size. Snack packs and bottled water three-area designated concept(5): Trucks each with an inflatable air-conditioned were also issued before departure to the mor- nn Green rest area for staff; tent, generators, flood lights, decontamina- tuary facilities. The team divided into three nn Yellow decontamination area; and tion and hand-washing facilities, protective teams each consisting of mass body repatria- nn Red high risk area where the bodies were clothing and body bags. As water and electric- tion trucks and a support vehicle. Staff trans- managed. ity supplies in Lagos are frequently disrupted, port was arranged by the South African Con- Although by the time the repatriation was generators were taken along. Water tanks sulate in Lagos. Each convoy was escorted by completed (63 days after the incident), the were taken along and filled by a pre-arranged a military security element from the Nigerian risk for Ebola and other communicable dis- contractor on arrival at Lagos airport. As the Defence Force, coordinated by the South eases had ceased due to the time-lapse since standard of diesel was questionable, fuel for African Military Attaché. It took 2 hours to off- death, the condition of the bodies remained the trucks and generators was also taken load vehicles and equipment, which included an area for concern. Therefore, the decision along. refuelling of the vehicles with diesel and dis- was taken to maintain the planned approach tribution of PPE and equipment. The internal of full protection against Ebola to test the sys- The plane was accompanied by a second Air- 50 litre water tanks of the disaster vehicles tem and to protect staff against all possible bus A320 passenger plane with 81 staff mem- were also filled by the contractor for use at risks. All staff therefore wore full protective bers, including: nn Command Element of 13 members including a medico legal consultant; nn 32 Forensic Pathology Officers; nn 16 Military Emergency Care staff trained in decontamination; nn 8 Environmental Health Officers to enforce and supervise decontamination; nn 2 Military Psychologist to manage continuous debriefing of staff; and nn 2 Technical staff to sustain vehicles and generators. A Chaplain accompanied the team for reli- gious observance, as well as representatives from the Department of International Rela- tions and Cooperation. A South African Police Fig. 3: Body Preparation Station at one of the Mortuaries

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doffed under direct supervision from the Envi- #"$& ronmental Health Officer: $ & nn % All staff changed from standard uniform to "$! "+ & "% ' theatre scrubs and waterproofed boots. #$% This attire was worn throughout in the "! $$!& $ "$&)$+ green area. "* $) "$&)$+ "* "$&)$+ "+&" "! $) "$&)$+ nn When entering the yellow area, staff "+&" "* - % & $) !"+&" &$&$ $) "$&)$+ %&'"!! & $) donned a second layer of protective equip- %&'"!! &'"! "! ment consisting of a water repellent (but .! $ breathable) paper cover-all with cap, a N- 95 respirator mask and first pair of cuffed "! /$ gloves, with cuffs worn under the sleeves "+ "$!&$* of the coverall. nn Before entering the red area they doffed a third layer of protective clothing consisting #! of a water repellent long sleeve gown, second pair of gloves and a full face visor. Graphic 1: Outlay of the Body Preparation Station When advanced decomposing bodies were transferred, red aprons were used which was ripped-off immediately and replaced nn The bag was then placed in a second white body numbers of bodies were also recorded when contaminated. bag and 15 ml formaldehyde solution was on the white board within each truck. On aver- Goggles were found not suitable due to high squirted between the layers of bags. This age it took 15 minutes to prepare a body for humidity and ambient temperature in Lagos. second bag was then also sealed. The repatriation. Gas masks with filters were taken along for vaporising formaldehyde created a Anecdotal, it was confirmed that no unpleas- offensive odours from decomposed bodies, formaldehyde gas-layer between the bags. ant odours from the decomposed bodies were but staff preferred not to wear it due to heat nn The sealed second bag was similarly detected after the triple sealing process. Pro- and humidity. decontaminated using a chlorine solution tection from formaldehyde vapours was At each mortuary, the identified bodies were and placed inside a third opaque metal achieved by utilising N-95 respirator masks pointed out to the team by the Nigerian staff lined body bag. and airflow in the tents from the air condition- and identification detail was confirmed by the nn Formaldehyde was again squirted between ing. SA Police Service. Identification tags were the layers and the outer bag sealed. Staff rotated every 40-60 minutes. Due to PPE attached to each body. Traumatic amputated nn The outer bag was decontaminated again and ambient temperature staff was forced to body parts were placed with the body in the using a chlorine solution. rotate within 60 minutes from donning red same bag and identified. nn The outer body bag was then identified, area protective clothing. The body was then manually moved in a mor- using a waterproof tag. This identification Staff decontaminated at each rotation tuary tray to the tented body preparation sta- was double-checked. A colour code system through a structured supervised process; tion. The body was manually transferred to a was used for all identification tags (bodies removing the first layer of PPE at the exit of prepared mortuary tray with a pre-positioned and body bags) to indicate Provincial desti- the red-area and washing their hands over body bag (all bodies were naked due to post nations within South Africa. inner gloves, walking through a foot-bath to mortem investigations conducted by the the yellow area where they removed the sec- Nigerian authorities). Bodies were then:- On completion of this preparation process the ond layer of PPE and decontaminated hands nn Bagged in a transparent body bag and bagged body was placed in a Stokes basket again. They then remained in the green area sealed. stretcher and moved to the pre-cooled mass- for 80-120 minutes where they were nn This bag was decontaminated by spraying body repatriation truck. These basket stretch- instructed and supervised to re-hydrate the bag with a chlorine solution (4000 ers fitted into numbered racks in the truck. To before dressing up to enter the red area ppm) and then wiping it down all around. assist with recordkeeping, the names and again(5). A psychologist was positioned in the green area throughout to debrief staff infor- mally and establish rapport with staff for formal debriefing at a later stage. Although clinical temperature monitoring equipment was taken along to monitor staff’s body temperature, it was not utilised due to the effective cooling of the tents by the air-conditioners. Snack packs with cool drinks and water were issued to all staff on arrival in Nigeria and meals were delivered at the Green Area by the South African Consulate. Only 74 bodies were released by the Nigerian authorities, due to their insistence on DNS identification as a sole identification method. On completion of the preparation and loading process, all teams and equipment were Fig. 4: Sealed and decontaminated body-bag moved into Transport Truck decontaminated. All support vehicles were

8 MCIF 3/2015 loaded and mass body repatriation trucks, service and then debriefing was planned for flow chart coupled with estimated times support vehicles and staff transport returned staff exposed to the decomposed bodies. assist in ensuring a seamless operation. to the military airport. Although showering in Lagos for all staff prior Self-sufficiency (down to micro-level) remains All personal possessions and valuables of the to the return flight was planned, it could not a critical requirement to ensure execution. deceased were collected and recorded by a take place due to a water supply failure at the The use of mobile mass body repatriation team of the SA Police Service. Lockable con- air force base. A full meal was served to all trucks in a cargo plane is a possible solution, tainers for the purpose of safekeeping of valu- staff members on arrival in South Africa and even if no cooling can take place in flight, but ables were taken along. all personnel participated in the memorial on condition that trucks are kept closed and By 20:00 local time, all teams reassembled service. Personnel then attended formal is appropriately isolated, for a period of up to back at the airport (total deployment 14, 5 debriefing sessions. Although the bodies 12 hours. hours) and after a memorial service, the were seriously decomposed and the condi- A three-layer bag system used in a three-area trucks and support vehicles were ready to be tions were unpleasant, no acute post-trau- preparation area (green, yellow and red) with re-loaded. It was not possible to connect the matic stress reactions have been reported to three layers of protected clothing is suitable trucks in flight to the aircraft power system, as date. for a high bio-safety risk operation. it was a chartered aircraft arriving in South Feedback from staff indicated that they felt The principles used in high security bio-safety Africa the day before the operation. The trucks safe and protected within the three-area sys- isolation can be applied in the handling of therefore had to be cooled at maximum on tem with three layers of PPE and the con- high-risk mortal remains. the ground and temperatures reached 2˚C. trolled decontamination. Cooling areas are essential for non-accli- Unfortunately the Nigerian authorities In the initial Ebola risk planning a decision mated personnel who are suddenly expected insisted the trucks be re-opened at the last was taken not to allow the opening of the to execute manual labour in high ambient moment and executed a time-consuming inner transparent bags and not to allow night temperature areas. Enforcing re-hydration is a inspection prior to departure, resulting in the vigils with the bodies. A procedure was com- critical precaution. loss of 4°C of cooling. Optimum re-cooling piled to only open the outer opaque bag in a Civil-military cooperation is possible in com- was then achieved in the short period prior to controlled environment and allow viewing plex operations through proper planning, role- loading the vehicles. through the transparent inner bags if families identification and appropriate command and An Import Permit for all bodies was generated insist. A directive to this regard was issued by control. and forwarded to South Africa, adhering to the Director General of Health to undertakers Post-traumatic stress can be prevented/lim- Port Health requirements in terms of the Inter- collecting bodies for burial. Due to the time ited by using a planned debriefing process national Health Regulations. delay, the Ebola risk however ceased, but which should include and integrate psycholo- The vehicles maintained an acceptable tem- families were still discouraged to view the gists with the team and then cleaning, rest perature during the 7-hour flight and arrived remains due to the appearance and subse- and feeding, ceremonial honours and then in South Africa at 12˚C. The vehicles were quent emotional trauma. Only one family debriefing. Informal psychologist interaction then driven off the plane, connected to three- insisted to opening the bags. throughout the operation enhances rapport phase electrical power inside a hangar and between staff and psychologist. immediately re-cooled reaching optimum 2°C Lessons Learned Cremation is not a generally cultural accept- within 2 hours. and Conclusions able procedure, but triple sealed bodies can A ceremonial memorial service was con- A mass body repatriation of high-risk bodies be viewed within restrictions to address ducted on arrival in South Africa, followed by over a long distance is a complex operation cultural practices. n the distribution of bodies, according to the requiring detailed planning. A detailed task- References: [email protected] colour coding, to regional mortuaries. All bodies arrived at the destinations within 48-hours after arrival in South Africa. On completion of the final DNA identification process of the remaining 11 bodies, a second AUTHORS repatriation operation was executed using a C-130 military plane and a container mortuary Colonel T.J. Ligthelm; MPA, B SocSc (Hon) (Nurs) on 5 February 2015. Due to the limited num- Dip Adv Nurse, H Dip Ed, RN, R AEA ber of bodies, local Nigerian transport was Senior Staff Officer Military Health Operations utilised to take teams to a single mortuary South African Military Health Service. and to transport prepared bodies to the con- tainerised mortuary on board the plane. The Address for the authors: same bagging procedure as in Phase 1 of the SAMHS Head Quarters operation was implemented. The mortuary Private Bag X 102 was continuously cooled using a generator Centurion positioned outside the C-130 until take-off 0146 and maintained the temperature during the South Africa flight. During the hour-longstop for refuelling First and corresponding author at Kinshasa, the generator was reconnected CO-AUTHOR to re-cool the mortuary. Upon arrival at J. Louw; N Dip Pol Admin Waterkloof Air Force Base, the 11 bodies were Deputy Director Forensic Pathology Service, Gauteng Department of Health immediately transferred to a mass body repatriation truck previously used. Lt Col J.T. Claassen; B Tech Env Health, N Dip Public Health The standard 5-step military debriefing Staff Officer Environmental Health, South African Military Health Service process of wash, a meal, rest, a memorial

MCIF 3/2015 9 MASS CASUALTY AERO-MEDICAL EVACUATION

T.J. LIGTHELM, L.A. WALLIS, S. MARTIN, P.J. VAN ASWEGEN (SOUTH AFRICA) Mass Casualty Aero-Medical Evacuation From the Nigerian Building Collapse back to South Africa

The article discusses the use of military aircraft for a mass casualty aero-medical evacuation of civilian casualties over a long distance. Structured approaches of a pre-determined team with pre- planned equipment are explained. The positioning of patients in the plane is planned according to a loading plan with specific triage priorities placed at specific levels. The lessons learned during the evacuation of 25 civilian patients after the Nigerian building collapse over a distance of 4500 km back to South Africa are highlighted.

Introduction As more information became available, the together as a team. This included a command During September 2014 at least four organ- South African Government by 16 September, element from the South African Military ised groups totalling more than 100 people, appointed an Inter-Ministerial Committee to Health Service and a co-commander from the travelled from South Africa to attend services manage the event under the chairpersonship National Department of Health. This grouping at the Synagogue Church of All Nations of the Minister in the Presidency and activated immediately started compiling a mass evacu- (SCOAN) under the charismatic leadership of its joint planning structure. This structure con- ation plan for possibly transporting a large its pastor, T.B. Joshua, in Lagos, Nigeria. sisting of all applicable government depart- grouping of casualties back to South Africa. On Friday, 12 September 2014 at approxi- ments, the South African National Defence mately 12:44 local time (1)a guesthouse on Force and the South African Police Service, is a Safety the premises of this church collapsed, injur- well-established coordinating capability and Both the intelligence community and the ing an undeclared number of casualties and was tasked to manage the response. Within Police Service assessed the safety of victims killing 115. Amongst the injured were a large this coordinating structure, a health cluster as well as possible relief teams, in view of the number of South Africans. Casualties were was formed of the National Department of political and security turmoil in Nigeria. This evacuated from the site in an uncontrolled Health and the Military Health Service. included an assessment of the possibility of operation to an unknown number of hospitals terror threats from the Boko Haram grouping in Lagos. No accurate name list was main- Response in Nigeria. It was concluded that the situation tained by the church and no central informa- This Health Cluster adopted the classic com- in the Lagos region is stable and that a relief tion system was created by the Nigerian mand algorithm of CSCATTT approach (5) (6) operation could be launched. authorities. to address the medical needs of the situation, Simultaneously, the health cluster assessed Lagos, with an estimated population of 21 namely: the health risks for such an operation. A case million (2)is served by approximately 54 hos- nn C: Command. of Ebola Virus Disease was introduced into pitals (3) (4). nn S: Safety. Nigeria on 20 July 2014 when an infected The initial information received was that there nn C: Communication. Liberian man arrived by aeroplane into Lagos. was a possibility of three South Africans nn A: Assessment The man, who died in hospital 5 days later, injured in the event. This picture slowly nn T: Triage set off a chain of transmission which infected started to evolve and by 15 September, it was nn T: Treatment a total of 19 people, of whom 7 died (7). Nige- clear that a substantial number of South nn T: Transport ria was only declared Ebola-free on 20 Octo- African citizens were either killed or injured in ber 2014 (8).Numerous allegations and non- the event. No information, however, was Command substantiated statements were made at the available on the condition of the injured or A joint co-command was established, consist- time that pastor Joshua had claimed to be the care they had received or required. ing of military and civilian personnel, working able to cure Ebola and was able to “wash off

本文讨论了使用军用飞机进行长距离大规 Cet article traite de l'utilisation d'avions В статье рассматривается применение Este artículo habla sobre el uso de 模航空医疗撤离伤亡平民的行动。阐述了 militaires pour une évacuation sanitaire военной авиации для массовой аэро- aeronaves militares para una evacua- медицинской эвакуации жертв среди 预先确定的团队使用预先计划的设备的结 aérienne de masse de victimes civiles sur ción médico-aérea masiva de víctimas гражданского населения на большие civiles a larga distancia. Se explican los 构化方法。根据特定验伤分类优先次序制 une longue distance. On y explique les расстояния. В статье также разъ- 定装载计划，确定患者在飞机中的具体位 approches structurées d'une équipe présé- ясняются структурированные подходы métodos estructurados de un equipo 置。本文着重讲解了将尼日利亚建筑物倒 lectionnée avec les équipements prévus. применения заранее определенной predeterminado con material progra- 塌事故受伤的25名患者运回南非（相距 Le positionnement des patients dans команды, использующей предвари- mado con antelación. La colocación de 4500多公里）的事件中吸取的教训。 l'avion est planifié selon un plan de char- тельно запланированное оборудова- los pacientes en el avión está prevista gement avec des priorités spécifiques de ние. Размещение пациентов в само- según un plan de carga con prioridades лете планируется в соответствии с de clasificación específicas en distintos niveaux spécifiques. On y met l'accent sur планом погрузки с конкретными прио- niveles. Se destacan las lecciones les leçons retenues lors de l'évacuation de ритетами сортировки на определенных 25 victimes civiles de l'effondrement d'un уровнях. В тексте также излагаются aprendidas durante la evacuación de immeuble sur 4500 km vers l'Afrique du уроки, извлеченные в ходе эвакуации 25 pacientes civiles tras el colapso del Sud. 25 гражданских пациентов после обру- edificio nigeriano a lo largo de una dis- шения здания в Нигерии на расстояние tancia de 4.500 km de regreso a Sudá- 4500 км в ЮАР. frica.

10 MCIF 3/2015 Ebola” from people exposed to the disease. clear from the onset that the medical condi- flight clearances for a military aeroplane over As the grouping in the building at the time of tion of the injured will need to be assessed at least three countries, was conducted by the the collapse were unknown, it was possible specifically to determine possible require- South African Air Force and DIRCO. that Ebola patients from Sierra Leone, Guinea ments and to determine the need for evacua- The assessment team also evaluated each or Liberia, where the Ebola outbreak occurred tion of the injured back to South Africa. patient for the possibility of exposure to Ebola or from Nigeria itself, may have taken a pil- On Thursday, 18 September 2014, Prof Lee Virus Disease as well as co-morbid condi- grimage to the church for healing. As the out- Wallis, Head of Emergency Medicine at the tions, which may influence air-evacuation. break in Lagos was also not yet under control, Universities of Cape Town and Stellenbosch, The assessment team warned that Ebola pre- the risk was that casualties may also have was deployed by commercial airline to Lagos caution measures were only in place in one of been exposed to Ebola in the hospitals in to assess the medical condition of the injured the hospitals visited. Although all patients Lagos after the event. These allegations, and to advice on evacuation. He arrived in were within the 21-day incubation period for which could be neither substantiated nor Lagos on Friday 19 September 2014 and Ebola, since their arrival in Nigeria, none of proven false, held the risk that some of the joined-up with the rest of the assessment them had any increased temperature. This casualties may have been exposed to Ebola team consisting of various government risk was continuously assessed by a special- Virus Disease. departments and the SA Police Service. ist advisory team from the National Centre for As many patients with other serious health As it was unclear at that stage how many Communicable Diseases (NICD) in South conditions were on a pilgrimage to the church South Africans were injured or where they Africa. As none of the patients met the case to seek healing, the risk for other communica- were treated, he had to work systematically definition for Ebola, the decision was taken to ble diseases such as extreme drug resistant through all applicable hospitals in Lagos only take adequate personal protective equip- tuberculosis, needed to be considered. As no tracing possible South African patients. ment along, but not to transport any patient in information was available on the health con- By Saturday morning 20 September 2014, an isolator (three negative pressure transport ditions of the South Africans who travelled to Prof Wallis gave the feedback that he had isolators were brought into readiness as a the church, or the infection control measures identified 26 South African patients from the contingency). The co-morbid communicable in the hospitals they were admitted to, com- incident in 5 hospitals. diseases were also assessed and the assess- municable diseases were identified as a seri- Additionally one uninjured orphaned child ment team found that none of the patients ous health safety risk and the need for pre- would need to be evacuated along with an had a known high-risk communicabledisease. cautionary measures planning was identified. injured sibling and a spouse who needs to The triage assessment was therefore limited travel with a patient. only to clinical injuries and co-morbid non- Communication It was clear from the assessment that the communicable diseases. To enable proper planning; communication patients were seriously injured, some with was established with frequent combined serious co-morbid health problems, which Treatment planning meetings. These meetings included required urgent medical interventions. The In preparation for the aero-medical evacua- a health cluster meeting, followed by a meet- best-practice interventions required were not tion, limited treatment was initiated in Lagos ing of the joint planning structure with role- necessarily readily available within Nigeria. by the assessment team. This was limited to players from all the government departments Based on the feedback from the assessment treatment advice to the local clinicians, as the and agencies involved. The first planning team, the South African Government opted to assessment team was not registered for prac- meeting took place on 16 September 2014 at evacuate the injured back to South Africa tice in the country. This situation necessitated 15:00. In the initial stages of the response through a mass aero-medical evacuation. the aero-medical evacuation team to prepare these meetings occurred three times per day. Various options were appreciated and the to initiate treatment at the airport prior to 14 meetings were held over a period of 10 most feasible option was identified to utilise evacuation. days prior to the operation. a rigged C-130 aircraft from the South African Due to the nature of the injuries, especially The South African Consul General in Lagos Air Force and staffed with a Mass-Casualty the serious orthopaedic injuries, a military was activated and a communication link Aero-Medical Evacuation Team from the South orthopaedic surgeon was included in the between the Consulate and the joint planning African Military Health Service (SAMHS). team to initiate treatment. Additionally the group was established. After the assessment hospitalisation needs were assessed and team arrived in Lagos, an Operational Room Triage communicated to South Africa in order to was established in a hotel in Lagos with tele- The assessment team assessed each patient enable the receiving hospital to adequately phone communication lines back to South clinically and a triage priority was allocated prepare. Africa. utilizing the military Priority 1, 2 and 3 The Aero-Medical team was informed of the Within South Africa, a communication centre approach. This information was captured in a need to establish a temporary Resuscitation with a 24-hour telephone line was estab- database and each patient allocated a patient Post at the airport in Lagos to stabilise lished at the Department of International number. This database with basic clinical patients for evacuation. Affairs and Cooperation (DIRCO) where family information was sent back to South Africa members could enquire about their next-of- where the Health Cluster received the first Transport kin. This was later expanded to a social serv- accurate data on 20 September 2014 at An evacuation plan was compiled and the ice response line. 00:34B–8 days after the incident. These team was briefed on the plan. patients were listed and evaluated as: Assessment nn Priority 1: 6 Doctrinal Approach As information was very limited on the num- nn Priority 2: 16 A mass casualty aero-medical evacuation was ber and condition of casualties it was decided nn Priority 3: 4 planned according to the military health serv- to deploy an assessment team to Lagos to Based on the triage categories and clinical ice doctrine (9). Theoretically, a Hercules join-up with the South African High Commis- information a mass casualty aero-medical C-130 can carry 72 stretchers but in this full- sioner’s staff, in order to execute an accurate evacuation team was then placed on a six configuration, extremely limited movement evaluation of the impact of the event. It was hour stand-by, whilst the planning for over- space is available with limited seating for

MCIF 3/2015 11 Case No Gender Primary Injury Comments Other Concerns Priority*

1 F Left Below Knee Amputation Healthy wound; mobilising slowly None 2 2 F Left Above Knee Amputation IV antibiotics; ready to mobilise Left arm soft tissue injury 2 3 M Right Below Knee Amputation IV antibiotics; ready to mobilise Urine catheter 2 4 F Right pneumothorax; ICD in situ IV antibiotics 2 5 F Right upper arm wound Infected wound; IV antibiotics Non-Insulin Diabetes 2

Moderate facial swelling; taking oral 6 F Le Fort III fracture fluids; mouth laceration sutured; 3 units blood transfused; HCT 33% 1 ready for surgery; IV antibiotics 7 F Pelvic injury – no fracture Ready for discharge Soft tissues injuries 3 8 F Left orbital blow out fracture IV ant ibiotics Left hand injury – soft tissue 2

Hematemesis Thursday two episodes; Right knee ligament injury for PoP 9 F Right pelvic injury (? Fracture?) rib fractures suspected but no 1 backslab; catheterised pneumothorax; IV antibiotics

Below knee PoP backslab; apparently Right bi-malleolar ankle fracture 10 M minor abrasion over fracture; IV Hypertensive on medication 2 with talar shift antibiotics Spinal injury neurological fall out Acute kidney injury on haemodialysis; 11 M Crush injury both legs; catheterised; right 1 needs dialysis Sunday morning shoulder fracture 12 F Soft tissue injuries both legs IV antibiotics; Enoxaparin Hypertensive on medication 2 13 F Soft tissue injuries Recovered

Rod through right breast exit right Insulin dependent; Hypertensive 14 F Chest wall injury 1 back; IV antibiotics; infected wounds on medication

Below knee PoP backslab; needs 15 F Right bi-malleolar ankle fracture 2 surgery Parotic laceration – missed injury; 16 F Left arm injury Elevation for swelling closing by secondary intention; 2 honey dressing. Back injury no fracture or 17 F Ready for mobilisation Non-Insulin Diabetes 2 neurology Above knee PoP backslab; IV Deteriorated later in day; 18 F Fracture right tibia 1 antibiotics; Enoxaparin confused; febrile.

19 F Leg and back pain No fractures or neurology; mobilising 3

No fractures or neurology; bed rest; 20 F Back pain 2 catheterised; Enoxaparin No fractures or neurology; bed rest; 21 F Back pain 2 Enoxaparin

Below knee PoP backslab; Enoxaparin; 22 F Left medical malleolus fracture Pelvic pain no fracture 2 being mobilised

No fractures or neurology; bed rest; 23 F Leg and back pain 2 Enoxaparin

PoP front slab; may convert to split full 24 F Right scaphoid fracture Hypertensive on medication 2 PoP; IV antibiotics for hand wounds 25 F Left arm and both legs injury Soft tissues; lacerations Hypertensive on medication 3 Spreading infection; dry dressings; IV 26 M Gangrene left 4 toes Multiple abrasions and bruises 1 antibiotics; needs amputation

Tab. 1: Patient List

* Priority for aero-medical evacuation

12 MCIF 3/2015 NKM 8 2.0 03/2015/A-E

To be MISSION READY Through KARL STORZ S.E.T.I.

KARL STORZ GmbH & Co. KG, Mittelstraße 8, 78532 Tuttlingen/Germany, www.karlstorz.com crew and little space for equipment. Due to these limitations, the SAMHS utilises only the central rigging of stretchers and not the stretcher positions on the outer sides of the plane. This space is reserved for team members and equipment. The aft stretcher rigging positions are also not used to allow space for high-care platforms. According to the SAMHS doctrine the rigged C-130 is divided in port and starboard sides. Each side is structured in columns identified by alphabetical letters from the front and then rows identified by numerical numbers from top to bottom. Staff is allocated according to this layout with: nn an emergency care practitioner per row of maximum five stretchers, nn a nursing officer is then allocated for every two rows; and nn a medical officer per side of the plane. A Priority 1+ area is established in the back of the plane with up-to four high care platforms. Each high-care platform is allocated a nursing officer and a medical officer is allocated per two high-care platforms. Each side of the plane is also staffed with a Fig 1: Outlay and Staffing Aeroplane warrant officer who co-ordinates and controls loading and off-loading as well as a technical file. Only one technical officer was available. A central emergency blood bank with fresh officer who maintains oxygen supply and elec- The team for this operation consisted of: frozen plasma and packed cells in portable tronic equipment. nn Commander refrigerators was taken along. No platelets An overall Military Health commander is nn 5 X Medical Officers (Incl. Orthopaedic were taken along due to a logistical chal- appointed for the plane with a warrant officer Surgeon) lenge. to support him/her. The commander is specif- nn 6 X Nursing officers Comfort equipment such as bedpans, urinal- ically not a clinician to ensure that command nn 8 X Emergency Care Practitioners bags and a chemical toilet was also packed and control is maintained without being side- nn 1 X Technical Support Officers per side of the plane. Due to the nature of the tracked by clinical needs of patients in evacu- nn 2 X Warrant Officers injuries, six scoop stretchers were included to ation. In total, a Mass Casualty Aero-Medical transfer patients from ambulance stretchers Evacuation Team consists of 23 members (9). Initially a Paediatrician was also included but to the aeroplane stretchers and four vacuum This team is supported by a minimum of two after reviewing the information of the injured mattresses were taken for spinal injuries. loadmasters from the Air Force. child it was found not necessary. Standard NATO-design canvas stretchers were This doctrine was practiced and tested by the The team reported to the Air Force base on 21 used throughout the plane for all the SAMHS 2 months prior to the event, which September 2014 at 02:00B ready for deploy- columns. These stretchers were equipped enabled the team to apply the doctrine, and ment. The plane took-off at 03:56B– 9 days with a linen pack with pillow, sheets and a the lessons learned during this operation. after the event. blanket. An aluminium space blanket was Food parcels were provided for the team for used underneath the patient for isolation and Aero-Medical Evacuation Team three meals in flight and adequate drinking additional blankets were available to keep Although the triage assessment only indi- water was made available. patients warm. (The patient compartment of cated 26 patients for evacuation, the risk the C-130 plane’s temperature can be existed that more patients may be found in Equipment adjusted to ensure patient and staff comfort. the chaos following the incident or that neigh- The doctrinal approach for equipment was This system however often overheats the for- bouring countries may have found some of adhered to (9). In this approach standard ward part of the cabin, to ensure a comfort- their citizens and requests South Africa to resuscitation equipment, monitors, suction able temperature in the aft.) It was decided evacuate these citizens back to Southern and oxygen are packed per column of five that due for the duration of the flight, all Africa as well. For this reason the decision stretchers. Additional support equipment to patients and the uninjured child will be trans- was made to prepare the plane for the full replenish this first line of equipment is added ported as stretcher cases, as adequate space load of 40 stretchers in the rigging and 2 high- per side of the plane. These include mass was available. care platforms. infusion packs with additional fluid as well as Two small orphaned children, aged 2 and The team was therefore constituted to drugs. 6 were amongst the patients. A donation of a address the full planeload of patients and not Each high-care platform carries its own oxy- teddy bear and a gift pack per child was necessarily only the patients on the triage list. gen, suction and resuscitation equipment. received from a private hospital group prior to The Mass Casualty Aero Medical Evacuation Four high-care platforms were available, but the flight and taken along. A nursing officer Team mobilised for this operation was based on the assessment teams’ findings was appointed to take care of these children adapted to reflect the expected patient’s pro- only two were loaded. in-flight.

14 MCIF 3/2015 To adhere to custom regulations, all equipment had to be declared to the custom authorities prior to the operation. This was a very time consuming process.

Road Transport Plan and Pre-Flight Treatment in Lagos The Assessment Team compiled a meticulous transport plan to transport all the patients from the 5 hospitals to the airport, based on clinical condition. All hospitals were within an 8 km radius from the airport. Each patient was allocated a number and these numbers were attached by identification bracelet to the patient. The very limited number of six ambulances (3 from the church, 2 private and one hospital ambulance) and one minibus were planned optimally to move the less serious patients to the aircraft first and then return to transport the more serious patients last. The purpose of this plan was to limit the out-of- hospital time of the critical patients to the Fig 2: Preparation of Patients for Evacuation minimum. On confirmation of the landing time of the menced. All chest drains were connected to plane in Lagos this plan was activated. One one-way valves for the flight. patient decided not to return on the flight and Two seriously ill patients required special pre- to return to the church, resulting in 25 flight treatment. The first patient had an iron patients and 2 uninjured passengers evacu- rod piercing her thorax with an accompanying ated. haemo-pneumothorax. She had no inter- The C-130 landed on 21 September 2015 at costal drain in situ and this had to be inserted 14:43B on the military apron of the Lagos before flight in the back of an ambulance by International Airport. An aircraft hangar space torch light. was made available to the team by the Niger- The second severely ill and unstable patient ian Air Force to establish a re-triage and had a Glasgow Coma Score of 6/15 (E1V1M4) resuscitation post. On arrival the team com- and required endotracheal intubation. The menced with the final rigging of the plane and patient had a pre-morbid mass lesion in the preparing all stretchers for receiving patients. pharynx and thus presented with an Fig 3: High-Care Platforms positioned in the aft All equipment was moved to in-flight posi- extremely difficult airway to manage. This of the aircraft tions and checked. The resuscitation area was patient was intubated and placed on a high- prepared to receive patients. Within 2 hours care platform, which allowed intensive care above. This allowed easy access to the prior- after landing, the patients started arriving. quality monitoring and support. ity 1 and 2 patient in flight, while the priority Patients were transferred from the ambu- The patient with the Le Forte III fracture was 3 patients who required less care in flight lances to the pre-determined triage and placed on the second high-care platform as were in the less-assessable positions. Due to resuscitation area. Prof Wallis re-triaged the this allowed the patient to be positioned in the limited number of patients (no additional patients and briefed the clinicians on the Fowlers position during the flight. patients were identified), only four stretchers patient’s condition. All patients were re-assessed for increased per column were used for this flight. temperature as result of the Ebola risk, but no The Warrant Officers were guided by the clini- In the triage area, the patients were assessed patient had any signs. cians, compiling a loading plan by allocating for: The warrant officers commenced with compil- specific patient numbers to each stretcher nn Severity of injuries. ing the loading plan for the plane, utilising position. As soon as the complete loading nn Type of transport support required such as patient numbers against stretcher positions. plan was available, loading started per side of vacuum mattresses or standard stretchers. A system of colour-coded rows per column of the plane, from the front to the back. The nn Requirements for pre-flight treatment. stretchers was utilised. team, supported by the Nigerian Air Force staff, were grouped into stretcher parties and During the assessment patients who had Loading Plan the stretchers carried on-board. (Attempts in spinal injuries were placed on vacuum mat- The most critical (often ventilated patients) the past to use wheeled base stretcher-carri- tresses to assist with in-flight stabilisation, are identified as Priority 1+ to be loaded on ers have proven not effective and manual comfort and safety during loading; four (4) the high-care platforms. Two of these plat- stretcher parties remain the most effective patients were immobilised on vacuum forms were available and patients were identi- method for loading). The Warrant Officer and mattresses. fied for these positions. a loadmaster checked and had to confirm that Numerous patients also required anti-emetics Each column of patients are then planned, each stretcher was properly secured. and analgesics pre-flight. Where applicable with planning the priority 1 patient at eye Due to limited space within a fully rigged intravenous lines were established and the level for a sitting attendant, a priority C-130 our experience is that it is very difficult administration of blood products com- 2 patient below and the priority 3 patients to manoeuvre stretchers past already loaded

MCIF 3/2015 15 stretchers, therefore each column is fully loaded before the next column is started. The high-care platforms are moved into position lastly and the critical patients brought on- board last. Loading a mass casualty evacuation aircraft is a labour intensive operation, which requires muscle strength from all members to carry and lift stretchers into position. Due to bureaucratic challenges within Nigeria the assessment team advised the plane to take-off as soon as possible, putting severe strain on the crew-duty time of the air crew. The average time to load a C-130 during exercises was 130 minutes (5, 7 min per patient/ side). In Nigeria due to the condition of the patients and the need for stabilisation intervention, this process took 245 minutes (19, 6 minutes per patient/side). By 22:30B all patients were loaded, the high- care platforms positioned and the two critical patients loaded. On 22 September at 00:05B Fig 4: Limited space available within the Fig 5: Off-loading drills with bearer-parties the plane departed from Lagos International aircraft Airport. No patient passed-away or seriously deterio- In coordination with the Aero-Medical Team In-Flight Care rated during evacuation. commander, the Receiving Commander called The in-flight evacuation was fairly uneventful ambulances forward, based on the re-triage due to pre-flight intervention. One patient was Arrival and Off-Loading Plan priority of the patients. The high-care ventilated in-flight utilising a transport vol- An off-loading plan was compiled for arrival at platform’s patients were off-loaded first and

ume-cycled ventilator with a FiO2 of 100% the Air Force Base in South Africa. dispatched to the receiving hospital. This was and a PEEP of 5-10 to maintain saturation. A Receiving Commander was appointed and a followed by a structured off-loading process Saturation was effectively achieved through- group of 30 stretcher-bearers was mobilised simultaneously on both sides of the plane. out the flight. The other patients maintained to be in position on arrival at the Air Force Ambulances were called forward, the patient saturation > 90% on cabin air and did not Base. off-loaded by the bearers and the in-flight require any additional oxygen administration. Thirty civilian and military ambulances were staff handed the care and clinical notes over Oxygen was however available at every mobilised to be in position on landing. Ambu- to the ambulance crew. As far as possible, column of stretchers. lances were grouped based on available staff only one patient, with their personal luggage, It was possible to mount intravenous infu- and equipment into Priority 1 ambulances was loaded per ambulance. As the ambu- sions to the stretcher position above utilising and priority 2 and 3 ambulances. Each ambulances were loaded, they formed up in a con- basic S-hooks. Very limited turbulence was lance carried its own crew, which was inde- voy and were escorted by traffic police to the experienced in-flight and no challenges were pendent of the stretcher-bearer parties. This receiving hospital. experienced with this mounting method. allowed for off-loading to continue without The orthopaedic surgeon was transported to A fuel stop was done at Kinshasa Airport tak- delaying ambulance evacuation. the receiving hospital immediately after ing 45 minutes, allowing staff to do a full re- The plane landed on 22 September at 10:43 arrival to brief clinical staff on the condition of assessment round of all patients. The fuel in Pretoria. On arrival of the plane, Port Heath the patients. Special arrangements were stop also allowed staff to use restroom facili- procedures for mosquitoes and custom proce- made for the orphaned children on arrival. A ties. dures were adhered to. Due to another activ- specific team accompanied them to the hos- Except for basic contact precautions protec- ity, a secondary air force base in Pretoria had pital where a social worker was waiting to tive equipment, no special personal protec- to be used. This base had to be officially receive them. tive equipment was used during the evacua- declared a temporary Port of Entry for custom A separate fatigue team with a truck was pro- tion. procedures. All equipment had to be re- vided to offload all the equipment, while a Each child received a soft toy to comfort them checked by customs authorities and all food- team was also pre-positioned at the receiving in-flight and a specific nursing officer cared stuffs left over, had to be collected as it may hospital to collect all stretchers and equip- for the children in flight. not be brought back into the country. A mas- ment as patients were off loaded onto hospi- Lighting in the passenger compartment of the sive media presence was experienced and a tal gurneys. plane is limited and headlights were used by specific media area was earmarked in A large group of government dignitaries were all staff members. advance. accommodated to welcome the patients back Clinical observations were measured and The off-loading plan was then activated. A to South Africa. These dignitaries were only recorded throughout the flight. Due to the road-cone corridor was marked out around the allowed access to the plane by the Receiving time spent preparing patients followed by the plane and pickets positioned to prevent any Commander after the critical patients were 10-hour in-flight care, the clinical team was ambulance from coming too close to the plane off-loaded and dispatched to the hospital. exhausted. A rotation system with 2-hour and to ensure a one-way circle route from A massive amount of personal luggage of the shifts was implemented to allow the staff a parking to exit. (Antennas from ambulances patients was delivered by the Nigerian author- rest break. This assisted with ensuring quality had damaged planes in the past during load- ities to the airport. This provided a serious patient care. ing and off-loading of pa tients). challenge with space, but it was loaded on

16 MCIF 3/2015 the loading ramp of the plane and therefore rest/sleep as the team in this event were injuries and are aware of their surroundings. had to be off-loaded first on arrival before any totally exhausted on arrival. Additional staff The availability of soft toys, such as a teddy patient could be off-loaded. must be planned for loading and off-loading. bear, comforts them in flight. Special precau- The use of military transport planes remains a tions need to be taken with orphaned children Hospitalisation Plan solution to evacuate large numbers of lying to ensure proper management and care. Due to the high publicity of the event, as well patients in a mass casualty event. The num- An information system for next of kin with a as condition of the patients, a decision was ber of stretchers loaded must however be bal- re-uniting plan with social work support is an taken to transfer and admit all patients anced with space to accommodate a proper integral part of a mass casualty evacuation initially to the Steve Biko Academic Hospital number of clinical staff and support staff and plan. in Pretoria, 12 km from the Air Force Base. allow for access to all patients. Our experi- This decision allowed for easy record keeping, ence is that a C-130 can optimally only Conclusion full re-assessment of all patients, availability accommodate 40 rigged stretchers and two Military medical air transport assets and of high-technology capabilities for critical high-care platforms or 50 rigged stretchers. teams can be utilised effectively in civilian patients, proper debriefing of all victims and a Mass casualty evacuation entails a large vol- mass casualty incidents, to evacuate large coordinated reception by government at a sin- ume of equipment. Separate vehicles must be numbers of patients, over long distances, on gle facility. The management and clinical staff planned with a team to load and off-load this condition proper assessment and planning is of the hospital were briefed prior to the opera- equipment. Placing a separate vehicle with done. The CSCATTT concepts itself serves as a tion, to ensure the hospital was ready to staff at the hospitals to collect all equipment guide to plan such an operation. receive patients. ensured that no equipment was lost in this Mass Casualty evacuation is a time consum- A re-uniting process with social work support operation. ing operation. This is not a hot-extraction for next-of-kin was planned at the receiving Planning to accommodate the personal lug- capability, as it required a secured airhead hospital. No next-of-kin were allowed at the gage of patients must be included in the plan. with time and human resources to assemble, air force base and all re-uniting occurred in Space must be planned for and a vehicle and prepare and load patients in a structured controlled circumstances out of public view, team to handle luggage proved essential. approach. n at the receiving hospital. Small children require special planning for Within 120 minutes after landing of the plane evacuation, especially if they have minor References: [email protected] all patients were admitted to the receiving hospital. From take-off to admission to hospital, the entire operation was executed in 12 hours. AUTHORS Lessons Learnt Pre-planning a mass casualty aero-medical Colonel T.J. Ligthelm; MPA, B SocSc (Hon) (Nurs) evacuation and practicing the process, with Dip Adv Nurse, H Dip Ed, RN, R AEA ; Senior Staff Officer Military Health pre-packed equipment, is of critical impor- Operations; South African Military Health Service. tance for the successful execution of such an operation. The sub-division of the plane into Date of Birth: 10 June 1955, Place of Birth: Middelburg, South Africa zones with staff and equipment allocated per Assignments: zone not only enhances control but ensures 1982–1996 Head of Disaster and Emergency Planning, Universitas Hospital, Bloemfontein, South that patient care is structured during flight. Africa and Chief Training Officer, Ambulance Service; 1996–2000 Head of Patient Care, 3 Military The team must be drilled in the procedure and Hospital, SAMHS; 2000–2009 Officer Commanding, School for Military Health Training, SAMHS; be in possession of the required travel docu- 2009-2012 Senior Staff Officer, Strategic Planning, SAMHS; 2012–2015 Senior Staff Officer, ments and vaccination records. Force Readiness and Military Health Operations, SAMHS Missions: Several missions and operations in the region including: 1994 Medical Commander, Merriespruit Mudslide Disaster; 2003 Medical Commander, Earth- Proper triage and assessment (if possible quake Response Force, Boumerdès, Algeria; 2013 Medical Coordinator, Bangui evacuations and prior to dispatching the team) is essential to repatriations; 2013 Commander, Field Hospital, Funeral of Mr Nelson Mandela; 2014 Medical ensure that optimum care and equipment is Coordinator, Nigeria Building Collapse; 2014 Coordinator SAMHS Ebola Virus Disease Planning available on-board the flight. In a large mass and member Ministerial Advisory Committee on Ebola casualty evacuation, an assessment team must be dispatched in advance to evaluate, Address for the authors: triage and prepare patients for evacuation. SAMHS Head Quarters Stabilisation prior to evacuation remains the Private Bag X 102, Centurion, 0146 cornerstone of successful aero-medical evac- South Africa uation. E-mail: [email protected]. The proper loading plan, based on triage cate- First and corresponding author gories and utilising column and row numbers is of the utmost importance for mass evacuation. CO-AUTHORS The loading and off-loading of a mass casu- L.A. Wallis, MBChB, MD, DIMC, Dip Sport Med, FRCS (Ed) (A&E),FRCP Ed, FCEM, FCEM (SA), alty evacuation plane is a labour intensive FEMSSA, FIFEM; Head of the Division of Emergency Medicine at the University of Cape Town and Stellenbosch University and the Assessor and Triage Officer for the Operation operation, which requires effective control Lt Col S. Martin, Wing Commander in the South African Military Health Service and the Mass and a large number of staff, physically able to Casualty Evacuation Team Commander for the Operation lift and load stretchers. P.J. van Aswegen, M Soc Sc (Crit C Nurs), BA Cur (I et A), MB Ch B; Medical Officer in the South Evacuating patients over such a long distance African Military Health Service and a Medical Officer On-Board requires the use of additional staff to allow

MCIF 3/2015 17 BUNDESWEHR COMMAND AND STAFF COLLEGE – MEDICAL SERVICES AND HEALTH SCIENCES DEPARTMENT

J. MEYER, J. KOCH, O. KRIETER (GERMANY) Military Medical Support in the Humanitarian Arena (MMSHA) NATO-Accredited Training for Civilian Healthcare Providers and Military Medical Personnel

The German Führungsakademie der Bundeswehr offers a course that addresses military medical support in the humanitarian arena in the form of a NATO-accredited training measure for civilian healthcare providers and military medical personnel. The course familiarizes the participants with the principles of medical support at the civil-military interface, offers a platform for discussion and allows for a practical application of skills and knowledge during a tabletop exercise. It provides an excellent opportunity to gain an enhanced understanding of the interface between the military and civilian sphere and serves as a forum for mutual exchange.

Course Overview As military forces face increasingly complex scenarios requiring crisis management on the sector of medical care that involves both civilian and military instruments, it is necessary to define their interaction at the civil-military interface by means of sound policy and doctrine. In addition to that, challenges also need to be addressed by appropriate education and training efforts. Whereas the doctrinal foundation was laid by Allied Joint Medical Publication 6 (AJMedP-6), the MMSHA course covers important aspects of humanitarian assistance in complex emergencies. Since 2007, the MMSHA course at the Führungsakademie der Bun- deswehr in Hamburg has evolved from a bina- tionally planned and conducted German/Dutch program to a NATO-accredited module. The current format of the course was developed in close cooperation with NATO’s Military Medical Centre of Excellence and in November 2014, the course was granted NATO “SELECTED” accreditation. The course is open to medical and non-medical military and civilian participants. This year, it was conducted in its new MMSHA Course Picture

德国德联邦国防军（Führungsakademie L'Académie d'Encadrement de la Bun- Академия руководящего состава La Führungsakademie der Bundeswehr der Bundeswehr）提供了一门课程，按照 deswher Allemande présente une forma- вооруженных сил Германии предла- alemana ofrece un curso que abarca el гает курс, который включает в себя 北约认可的民用医疗服务供应商和军事医 tion qui s'adresse à l'aide médicale mili- apoyo médico militar en el ámbito военно-медицинскую помощь на гума- humanitario en forma de medida for- 务人员培训措施，针对军事卫勤保障在人 taire dans le domaine humanitaire sous нитарной арене в виде аккредитован- 道主义领域的工作进行培训。该课程使学 forme de mesures de formation certifiées ной НАТО программы обучения для mativa acreditada por la OTAN para 员熟悉军民交流的卫勤保障原则，提供了 par l'OTAN, pour les prestataires civils de гражданских медицинских учреждений proveedores sanitarios civiles y perso- 一个讨论平台，并可在桌面演练中实际应 soins et le personnel médical militaire. La и военно-медицинского персонала. nal médico militar. El curso familiariza 用技能和知识。该课程提供了增强军事和 formation familiarise les participants aux Курс знакомит участников с принци- a los participantes con los principios 民用领域之间交流理解的一个极好机会， principes de l'aide médicale à l'interface пами медицинской помощи в военно- del apoyo médico en la interfaz civil- гражданском взаимодействии, предла- militar, ofrece una plataforma para el 并成为相互交流的论坛。 civil-armée, offre une plateforme de dis- гает платформу для обсуждения и debate y permite una aplicación prác- cussion et permet la mise en pratique des позволяет применить знания и навыки compétences et des connaissances lors на практике во время штабных учений. tica de habilidades y conocimiento d'exercices de simulation. Cela offre éga- Это является прекрасной возмож- durante un ejercicio de simulación. lement une excellente possibilité d'acqué- ностью получения более глубокого Supone una gran oportunidad para rir et améliorer la compréhension de l'es- понимания взаимодействия между ganar un conocimiento mejorado sobre военными и гражданскими службами и pace entre le civil et le militaire et sert de la interfaz entre la esfera militar y civil служит форумом для взаимного y sirve de foro para el intercambio forum c'échanges. обмена. mutuo.

18 MCIF 3/2015

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Course Schedule format for the second time. From 18th to 25th May 2015, 20 field-grade officers coming from Germany, Hungary, the Netherlands, Norway, the United Kingdom and the United States and representatives from the civilian field completed the module at the Führungsakademie der Bundeswehr in Hamburg. Principles at the Civil-Military Medical Interface The course is basically divided in two parts: During the introductory phase, several presentations are held, aiming at a deeper understanding of the civil-military environment. The purpose is to familiarize the participants with both the perspective of civilian actors and the perspective of military medical leadership in terms of principles and challenges. In this context, the program focuses on the role of international, governmental and non-governmental Brigadier General (MC) Dr. Kowitz, MBA, Director of the MilMedCOE actors and organizations while discussing potential military contributions. Therefore, the the Ebola outbreak in West Africa in 2014 dards, the principle of “do no harm,” and the interaction among these actors is discussed in from a German perspective. Lessons learned “code of conduct” adopted by the Red Cross/ terms of opportunities for coordination, collab- addressed epidemiological findings, the coor- Red Crescent movement and major NGOs oration and cooperation but also against the dination of this mission at the strategic level were explained in detail. The keynote lecture background of constraints and restraints. and the conduct of the mission, which revealed provided by the Director of the Centre of Introducing the perspectives of UN OCHA and the strengths and weaknesses of military med- Excellence for military medicine (MilMedCOE) the ICRC as decisive actors, the principles of ical contributions. Whilst military contributions concluded the introductory part of the course humanity, impartiality, neutrality, and inde- usually come with capable means of com- and set the scene for the following tabletop pendence are emphasized and compared to mand, control and communication and also exercise. Throughout the course, particular military objectives that may differ from these with sufficient logistic support and capable emphasis was placed on appropriate stan- principles. Moreover, important aspects such medical intelligence and health surveillance dards of healthcare supported by military as accountability on both sides of the inter- assets, all actors involved have to be fully medical forces in case of a humanitarian cri- face, mutual respect, and cultural awareness aware of the fact that a potential conflict sis. These standards need to be acceptable, are covered in the introductory briefings. between military objectives and humanitarian credible and sustainable in terms of being Linking the theoretical part of the course to the principles might hamper the overall mission. embedded into a system that allows for tabletop exercise, this year’s course provided Furthermore, the “Sphere Project” providing a appropriate follow-up treatment in the long insight into the international response to set of universal minimum humanitarian stan- run.

MCIF 3/2015 19 Tabletop Exercise The second part of the course saw a tabletop exercise with a NATO exercise scenario that was only recently introduced to the Führungsakademie and that facilitates operational level planning in general staff officer courses. It is about an escalating crisis taking place in a fictional African region with an ongoing UN mission in a failing state, with commitment of international and non-governmental organizations and with the deployment of a robust NATO force. Adapting the scenario to the purpose of the MMSHA module, the course directors provided information for this exercise that focused on a response to a deteriorating humanitarian situation in a complex strategic environment. During the exercise, the course participants formed groups and assumed roles of civilian and military actors. They were tasked to develop mutually accepted civil-military solutions to challenges Tabletop Exercise arising during humanitarian assistance in a crisis. A UN OCHA representative chaired several civil-military meetings, during which the them a forum that contributes to mutual learning objectives. Moreover, the experience participants were required to clearly define understanding in a modern educational envi- of a multinational environment is of utmost their roles and responsibilities, identify poten- ronment. There is no doubt that this course importance, since approaches to problem- tial contributions from different perspectives, hugely benefits from the contributions by a solving do not only differ among civilian and and develop a common approach to the solu- selection of civilian organizations, which is a military actors but also among military med- tion of crisis-related medical problems. More prerequisite for achieving the aforementioned ical services of different nations. n specifically, the participants were asked to consider the following aspects: n What are the most pressing requirements AUTHOR in this humanitarian crisis? n What are credible contributions of single Colonel (MC) Dr med Jürgen Meyer, M Sc organizations to the overall effort? born 03 Oct 1968 in Rheine, married, 2 children n What is the role of military medical support acceptable to military forces and the inter- Assignments national community? 1988 Basic Military Training, MedBn 6, Itzehoe n Which complementary capabilities may be 1989 – 1995 Medical School, WWU Münster provided by different actors and how can 1995 – 1998 Clinical Training, Bundeswehr Hospital Hamm they be coordinated? 1998 – 1998 Qualifications in Family Practice, Sports Medicine, and Emergency Medicine n Which financial arrangements for funding 1998 – 2000 Medical Officer, Medical Center Augustdorf and reimbursement are in place? 2000 – 2002 Company Commander, 2./MedRgt 7, Hamm Feedback on the groups’ performances was 2003 – 2003 Lecturer at the Bundeswehr Führungsakademie, Hamburg provided by facilitators from civilian organiza- 2003 – 2005 General Staff Officer Course, Bundeswehr Führungsakademie, Hamburg tions and from military medical experts. 2005 – 2006 Section Head G3 International Relations, Joint Medical Forces Command, Koblenz Evaluation and Conclusion 2006 – 2008 Staff Officer Medical Policy, Doctrine and Education, Allied Command Trans- Based on the feedback of course participants, formation, Norfolk (USA) it can be stated that the course has strongly 2008 – 2010 Bn Commander RMRFC FOF, Schwanewede, M. Sc. Health Management, enhanced the knowledge and skills of military Univ. Koblenz/Landau medical planners and civilian healthcare 2011 – 2011 SO International Relations, MOD Medical Staff II 1, Bonn providers. The participants seized the oppor- 2012 – 2012 MA oft the Surgeon General of the Bundeswehr, MOD, Bonn tunity to learn about civilian requirements 2012 – 2014 Branch Head Medical Command HQ I 2, Capability Management, Koblenz and the military perspective. Applying this since Nov 2014 Bundeswehr Führungsakademie, Chief of the Medical Service and Health Sciences Department knowledge during the tabletop exercise cer- Deployments: tainly helped them to deepen their under- 1997 SFOR, Field Hospital, Rajlovac standing of these aspects. The most valuable 1998/1999 KVM, Mobile Medical Physician Team, Tetovo achievement of this course, however, was 2000/2001 KFOR, Medevac Company Commander, Prizren that it facilitated transparency and provided a 2010 ISAF, Deputy Medical Advisor IJC, Kabul platform for exchange at the interface of the civilian and military medical spheres. The pur- Address of the author: pose of this course is not simply to familiarize E-mail: [email protected] the participants with this interface but to offer

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A. PANARITI, L. NIKOLLARI, M. DULI (ALBANIA) Clinical and Epidemiological Assessment in Visceral Leishmaniasis

About 12 million cases of leishmaniasis exist in the world, with 1.5 – 2 million new cases occurring each year, of which 1 – 1.5 million cases are diagnosed with skin leishmaniasis and 500,000 cases with visceral leishmaniasis. This article describes the experience in the assessment, diagnosis and treatment of some cases hospitalized in Military Hospital Tirana.

Introduction It is estimated that about 12 million cases of leishmaniasis exist in the world, with about 1.5 – 2 million new cases occurring each year, of which 1 – 1.5 million cases are diagnosed with skin leishmaniasis and 500,000 cases with visceral leishmaniasis. There are 500,000 new cases of visceral leishmaniasis each year, 90% occur in Bangladesh, Brazil, India, Nepal and Sudan. Mediterranean Visceral Leishmaniasis affects small children. The disease is present in Italy, France, Spain, Greece, Croatia, Albania, Turkey and other Mediterranean countries. The number of cases with visceral leishmaniasis have increased in Albania during 1991 – 1994 as a result of movements of population from the countryside (along with pets like dogs, etc.) to cities and as a result of interruptions of application of insecticides and other collective health measures. Many districts of our country are known as endemic areas of Leishmaniasis like: Gjirokastra, Vlora, Himara, Saranda, Fier Map of visceral leishmaniasis around the world. (Seman area), Kruja, Tirana and Shkodra. Often no epidemiological connection is found between the place of infection, country and etc) show numerous cases of Leishmaniasis. time of occurrence of the disease. However, the number of cases with visceral Seasonality of the disease is annual, as can leishmaniasis in adults admitted to No.4 Hos- be shown in all seasons as a result of its long pital and other hospitals of the country, has incubation period. been rather small. During the years 1991 – 2005, in the lower Epidemiological Data areas of Albania and through river valleys The dates of many doctors (Prof.S.Bekteshi cases with leishmaniasis occured (Table 1). and many other pediatricians in Kruja Tirana, In Albania, there was an increase of cases of

全球约有1200万例利什曼病患者，每年新 Il y a dans le monde environ 12 millions В мире встречается около 12 миллио- En el mundo existen cerca de 12 millo- 发病例有150万至200万，其中100万至 de cas de Leishmaniose, avec l'apparition нов случаев заболевания лейшманио- nes de casos de leishmaniasis, de los зом, при этом каждый год происходит 150万病例被诊断出患有皮肤利什曼病， chaque année 1,5 à 2 millions de nou- cuales entre 1,5 y 2 millones se diag- 1,5 - 2 миллиона новых случаев забо- nostican como leishmaniasis cutánea y 50万例患有内脏利什曼病。本文介绍了 veaux cas, dont 1 à 1,5 millions de leish- левания, из которых 1 - 1,5 млн слу- Military Hospital Tirana军队医院部分住院 maniose cutanée et 500 000 cas de leish- чаев получают диагноз кожного лейш- 500.000 casos como leishmaniasis vis- 病例的评估、诊断和治疗经验。 maniose viscérale. Cet article décrit маниоза, а также 500000 случаев ceral. Este artículo describe la expe- l'expérience de l'évaluation, du diagnostic висцерального лейшманиоза. В данной riencia en la evaluación, diagnóstico y et du traitement de quelques cas hospita- статье описывается опыт оценки, диаг- tratamiento de algunos casos hospitali- lisés à l'Hôpital Militaire de Tirana ностики и лечения некоторых пациен- zados en el Hospital Militar de Tirana. тов, госпитализированных в Военный госпиталь Тираны.

22 MCIF 3/2015 Leishmaniasis after 1990, when in Tirana Years 90 91 92 93 94 95 96 97 98 99 00 01 Total and other cities of Albania, the free movement of people bagan, migrating from the Visceral L 120 77 58 40 76 108 75 83 146 88 95 142 1108 countryside to the towns. In this period, Skin L 7 0 1 131312205 12 20 5 5 1010171220 17 12 20 together with the people came pets, especially dogs, which increased in the cities, Years 2002 2003 2004 2005 2006 2007 2008 2009 2010 close to restaurants and hospitals with cases 129 118 “ “ “ “ “ “ “ kitchens. Also during this period, cross- infection with leishmaniasis between people Tab. 1: Official data recorded during the years 1990 – 2003. and dogs increased. During the 12 years 1990 – 2001, in Albania, The purpose of the study is to present our Clinical findings cases percentage there were 1108 cases with visceral leish- modest experience in the assessment, diag- manisis. Most cases were recorded in the nosis and treatment of some cases hospital- Temperature 14 100 years 1993, 1995 and 2001. Most of these ized in Military Hospital Tirana. Pale face 12 85 cases, about 87 – 92% were in the pediatric Sweating 8 57 age, 60 – 65% in the age group 0 – 4 years. Material and Results Ascites 2 14 70 – 90% of the cases where found in rural 14 cases (all males) with an average age of Epistaxis 1 1.4 aereas, mainly from Elbasan, Gramsh, 20 – 24 years were studied. Of these 5 were Hepatomegaly 14 100 Gjirokastra, Kruja, Kukes, Lezha, Librazhd, soldiers belonging to the period 1980 – 1985 Splenomegaly 14 100 Shkodra, Mat, Tropoja. During 2002, there and 9 cases were civilians belonging to the were 129 cases with visceral leishmaniasis period 1998 – 2000. It should be emphasized Adenopathy 2 14 (incidence 4.2 % ooo inhabitants); while in that the latter were refugees returned from Weight loss 14 100 2003 there were 118 cases with an incidence Greece, who had worked mainly in the area of Skin Exanthema 3 21 of 3,8 % ooo. During the period 1990 – 1991, the Aegean Sea. and onwards, there was a large immigration These data are presented in Table 2. Tab. 4: Clinical data. of rural population to urban centers. In many As seen in the table, only 21% of cases had been cases, the new residents brought with them diagnosed properly. The remaining 79% present year Soldiers Civilians animals and especially house dogs in growing important data that should encourage early numbers. These must be seen potential 1980 – 1985 5 – diagnosis and consideration of consequences of sources for the increasing number of leishma- 1998 – 2000 – 9 delay. Therefore we think that early detection is niasis cases over the years 1990,1995,1998 an important factor for treatment, prognosis , and 2001. In our opinion, the number of Tab. 2: hospitalized patients. state of patient at the end of disease. cases with leishmaniasis must have been Clinical data as basis for diagnostics are pre- great; unfortunately, during this period, not Distribution by year is not important because sented in Table 4. only anti-epidemic rules were neglected but of the small number of hospitalized cases. Also important are data from complete blood cell also administrative measures like registration One of the important data that we want to count, especially leucopenia, or hypersplenism. and denunciation of infectious diseases. In present, is about the diagnosis of cases in our As seen from the table, there are two main these years there have been some deaths hospital. The data are presented in Table 3. groups of signs according to the predomi- from visceral leishmaniasis, also cases with nance in percentage delayed diagnosis of cutan and visceral leish- First group: Fever, hepatomegaly, spleno- Initial DIAGNOSIS cases percentage maniasis. megaly, weight loss, sweating. Visceral leishmaniasis affects males more Febrile status for 3 21 Second group: Ascites, epistaxis, adenopathy determination than females with a ratio of 2:1, with an aver- and exanthema. age age of 27 years. Leishmaniasis is found Syndrome 5 35 The main changes in the context of peripheral hepato-lienale more often at altitudes below 600 m, extend- blood count are shown Table 5. ing three ecosystems: northern, central and Observation for 3 21 southern. Endemic situations predominate in Leishmaniasis First examination Second examination Shkodra, Kruja, Tirana, Gjirokastra and Brucellosis 2 14 3250000 3800000 Saranda. Clinically, anemia was found in 92 % 3800000 4150000 Typhus Abdominalis 1 1.4 of patients, leucopenia in 100 %, thrombocy- 3330000 3800000 topenia in 86 %, Tab. 3: Data on diagnosis. 3700000 3750000 hepatosplenomegaly in 100 % of cases. 3960000 4555000 Most cases were treated with Glucantime Clinically characterized by hepato-lienal syn- 2500000 3900000 which gave positive effects in 90, 41 %. Allop- drome, extended temperature, sweating, pro- 3700000 4260000 urinol and Lomidin was also used for treat- gressive decline in weight, anemia, leucope- ment. nia and hypergammaglobulinemia etc.. 3100000 4100000 In our country, this disease has increased The tendency for a sub-acute and chronic 3840000 4070000 because of massive movements of popula- decors as consequence of delayed or wrong 3320000 4200000 tions after 1990-1991, the termination of the diagnosis ( like brucellosis) resulted in pro- 3800000 3800000 use of insecticides and increased number of longed febrile conditions, as these patients 2560000 3960000 street dogs. These factors increased 3 – 4 were referred from one doctor to another or 3020000 3780000 times the prevalence of the disease, compar- from one hospital to another, so complica- 3260000 3560000 ing 1964 – 1965 data to those of the period tions appeared and, as a result of secondary 1985 – 1994. infection, prognosis was not good at all. Tab. 5: Data on red blood cells.

MCIF 3/2015 23 Statistical Processing average = 121000, DS = 30600, V = 25 % .. While serology is performed in 6 cases and First examination: Average = 3440000, From these data we can see that even resulted positive in all of them. The data are DS = 403000, V = 11.7 %, platelets have a significant reduction. (we presented in Table 10. average error = 109000 don’t have second measurement of platelets) Second examination: Average = 3970000, In Table 7 are provided data on erythrocyte Discussion DS = 231000, V = 3.8 %, sedimentation. Leishmaniasis, rightly called soldier’s and emi- the average error = 62000. grant’s disease who may receive or become Based on this simple statistical processing First examination Second examination infected in endemic areas and because of its turns out that the differences between the 70 28 long incubation period it appears in distance first analyses of red blood cells and the sec- 75 25 from the time of infection. In this way we have ond are in about 2 weeks, so the difference 32 15 a discrepancy between the infection, incuba- is not significant and therefore the amount of 48 12 tion and manifestation of the disease on one red blood cells is not a criterion for the state 38 28 hand, in relation to endemic area and the time of the patient. Even in the subsequent analy- of appearance of the disease. 42 22 sis of these cases red blood cell number has We have noted that in almost all cases, the 45 24 been increasing slowly. appearance of the disease is after people White blood cells data are presented in Table 5. 46 32 have left the countries where have received 38 18 the infection. Therefore accurate and persist- First examination Second examination 44 16 ent epidemiology survey plays an important 3200 4200 37 17 role for the management of the disease. 3000 4350 55 21 Besides epidemiology survey the presence of hepato-splenic syndrome, (especially double 4900 4800 64 22 increase of liver and spleen size), laboratory 3800 5700 54 23 data, (especially expressed leucopenia), pos- 1700 6200 Tab. 7: Data on erythrocyte sedimentation. itive serology and bone marrow aspiration 1500 7000 establish an early diagnosis . 3000 8000 Average= 50.5, DS = 12, V = 23.7 % Early diagnosis in our cases was conducted 2500 8200 at admission; for the soldiers as a result of health service 3600 8100 Average = 21, DS = 4.6, V = 22 %. organization in the army. While emigrants 4500 8100 As we can see we have significant changes so were diagnosed later and this affected the 3800 3900 the sedimentation is an important indicator of course and prognosis of the disease. improvement and stabilization of the patient. According to the table of clinical data we 3980 5800 Liver enzymes data are presented in Table 8. noticed that fever, hepato-splenic syndrome, 3000 6800 From the data above the doubling level of weight loss, and sweating encountered in 2700 6200 liver enzymes does not progress in parallel over 50 % of cases . with liver enlargement. According to the seasonality of our cases we Tab. 5: Data on White blood cells and especially lymphocytes. BUN is raised in 2 cases with 90 and 120 encountered more in the summer season while respectively and creatinemia with 1.5 and 2.4. many authors encounter in the spring. Another Average = 3150, DS = 814, V = 25 % for the In other cases the results were within the nor- author belongs to other season. This explains first examination; mal range. that the disease has a long incubation time Average = 5800, DS = 1000, V = 17.25, for Changes in electrophoresis are presented in and therefore can be met throughout the year. the second examination; Table 9. It is performed in 10 cases. Many districts of our country are known as These data show that the difference is con- From datas on the table we see changes in endemic areas of Leishmaniasis like: siderable and the quantity of white blood protein fractions but without any significance Gjirokastra, Vlora, Himara, Saranda, Fier cells is variable and serves as a test for the in their total. (Seman area), Kruja, Tirana and Shkodra. positive progress of the disease. Data from bone marrow aspirations realized in 8 Our soldier cases , who are diagnosed in the Platelets data are presented in Table 6. cases have resulted positive in 6 of them or 80%. years when the military has been over 24

Number Quantity ALT 60 70 60 40 55 35 30 25 35 40 15 15 15 20 1 81540 AST 70 90 120 60 65 40 40 30 35 20 30 30 30 25 2 96000 ALT: Average = 40, DS = 10.8, V = 52%. ASt: Average = 50, DS = 28.5, V = 56%., where the changes 3 89000 are the same in both types of liver enzymes. 4 134000 Tab. 8: Data on liver enzymes. 5 152000 6 180000 12345678910MesDSV 7 192000 Albumin 34.9 53.2 42.4 48 42.2 44 43 46 44 48 44.5 4.6 10.3 8 88000 Alfa 1 6 5.10 9.8 6 3.8 10 9 6 10 9 6.7 2.4 35 9 132000 10 136000 Alfa 2 7.9 7.3 13.4 10 13.4 11 10 7 14 10 10.4 2.5 24 11 98000 Beta 7.9 4.5 6.4 10 6.4 12 13 9 12 12 9.3 3.9 41 12 135000 Gamma 43.3 22.9 34.2 26 34.1 23 25 24 30 21 27.3 7.4 23

Tab. 6: Data on platelets. Tab. 9: Data on electrophoresis.

24 MCIF 3/2015 treatment can be explained by activation of Antibody 1/320 1/850 1/779 1/587 1/324 1/640 1/227 1/799 1/322 titer lymphocyte B responsible for hyper gamma- globulinemia. Tab. 10: Data on serology. Some authors, during the disease have found antileishmania antibodies and have noticed months, we think that the infection was taken In blood cell count, in all cases we see that the humoral immune response in leish- from the districts that have been as follows: mononucleosis syndrome with expressed maniasis is increased and in some cases Himara- 1 case, Kruja- 1 case Shkodra- 2 neutropeny. Severe neutropeny is the main exaggerated, as seen in Table 9. cases, Gjirokastra -1 case. And emigrants who cause for secondary bacterial infections and it Our opinion is that the infection leads to have worked for 2 – 3 years in Greece (mainly is explained by bone suppression. immunodeficiency because after treatment in the area of the Aegean), were treated with Increased erythrocyte sedimentation is a conse- with antileishmania medications immune antibiotics for different disease, without suc- quence of the destruction of serial protein frac- cell parameters are completely neutralized, cess and the extended fever forced them to tion ratio with each other and erythrocyte mass. but on the other hand, people with acquired return in Albania where they are diagnosed High levels of eritrosedimentation have prac- immunodeficiency or those that use corti- and treated for leishmaniasis. Clinical signs tical value but it is not a specific diagnostic sone therapy are predisposed to infections like ascites, epistaxis, adenopathy ,exanthem test. The data are presented in Table 7. Ery- and further infection aggravate this situa- despite that they are rarely met ,should be throcyte sedimentation changes at the begin- tion. noted that they indicate serious illness. ning of treatment and at the end of it are very Hepatic cytolysis is almost constant with Great help in the diagnosis of disease have important and this is confirmed by the statis- increasing or doubling in over 50 % of cases been awarded to complete blood cell count. tical data presented, together with the table. before starting the treatment. While their Anemia is a result of several factors such as 3 is found in 5 of our cases, and it is normalization has progressed in parallel with hemolysis, breaking of or fall of granulocytes explained by low production of platelets due the improvement of the major clinical signs. and platelets as a result of the action of the to bone marrow inhibition. Their reduction Our opinion remains that it is a result of parasite in bone marrow cells, replacement of favors epistaxis, ecchymosed. anemia which leads to hypoxia hepatitis, parenchymatous cells by phagocytic mononu- Another important data is electrophoresis, hypoproteinemy from secondary bacterial clear cells infected by Leishmania, autoim- which is presented in Table 9. infections and granulomatosis hepatitis. mune cells and by hemodiluition. In our cases Electrophoresis changes in favor of increasing In 2 cases we observed increase on uremia they presented with hypochromic anemia. gamma globulin that return to normal after and creatinemy and we think they can be

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explained from the deposition of circulating Conclusions 5) Sedimentation is not important in relation immune complexes in the kidney, so the 1) The number of cases with visceral leishma- to the improvement and stabilization of appearance of a Glomerulonephritis with niasis increased / grown in Albania during the disease. hematuri, protein Uri and renal failure. 1991 – 1994 as a result of movements of 6) Often no epidemiological connection is population from the countryside (along found between the place of the infection In serology , an average of 1/550 sometimes with pets like dogs, etc.) to cities and as a and the country and the time of occurrence have served in the definitive and rapid diag- result of interruptions of application of of the disease. nosis and treatment of the disease. insecticides and other collective health 7) Seasonality of the disease is annual, as The fact that bone marrow aspiration results measures can be shown in all seasons as a result of positive in a high percentage (80 %) espe- 2) Cases with the "skin Leishmaniasis" were its long incubation period. cially in soldiers hospitalized 2 weeks after obviously decreased, perhaps as a result of 8) Immunodeficiency signs are reflected in the temperature and in 2 cases of emigrants the derecognition of cases with skin infection., electrophoresis and its improvement is means its diagnostic importance and 3) The quantity of red blood cells grows slowly in loyal to disease improvement. priority. relation to the improvement of the situation. 9) Hepatic cytolysis is present and goes paral- While positive serology realized in terms of 4) The quantity of white blood cells indicates lel with the condition of the patient. n hospitalization means late diagnosis and of positive progression of the disease. References: [email protected] course the performance and results of treatment are different from cases diagnosed earlier. (Especially emigrants). AUTHORS Treatment, is done with glucantim ( Meglu- mine antimoniate is a pentavalent antimony), LTC (ret) Agron Panariti, Ph D, MD A, for two weeks then two weeks rest and then Specialist in infective diseases, Military Hospital and Dean of Medical a second cycle again.. Glucantime action in Sciences Faculty, “Kristal University” of Tirana, Albania leishmaniasis still retains its effect in our Born 21/October 1949. country. Experience: August 2012, Dean of the Faculty of Medical Sciences "Univer- In addition to treatment with glucantime we sity crystals". 2012, Lecturer in the matter of infective diseases. 2006 – 2012, physician at Sigal used antibiotics for secondary ) Insurance Company. 1999 – 2011, teacher at "Faculty of Medicine", "Medikadent" University. Blood transfusion in severe forms of anemia 2010 Practice for “Abdominal Ultrasound” at NYU (New York University), USA. 2007 – February is performed in 5 cases with good replace- 2010, Physician in the "Institute of Military Medicine".2003 – 2007, Head Therapist at SUQU ment effects. (Military University Central Hospital). 1991– 2003, Head of the Department infectious diseases at CUMH, 1986 – 1991, internist at Infectious disease department in CUMH. 1984 – 1986, Postgra- We have noticed the dominance of fever duate in Infectious Disease. 1976 – 1984, Physician in naval forces, 1969 – 1971 N / doctor in a around day 3 – 5 from the beginning of treat- military unit. ment. Address of the author: Our final results were; 13 cases recovered Spitali Ushtarak Qendror Universitar and 1 dead. Rruga “Lord Bajron” Laprakë, Tirana, Albania In the prognosis of the disease except E-mail: [email protected] and [email protected] the time of diagnosis other factors plays First and corresponding author an important role such as age, tuberculosis, malnutrition, chronic diseases etc. CO-AUTHOR Our patient that died had TBC, he made Colonel L. Nikollari ascites, renal failure and secondary bacterial Phd, Epidemiologist infection. Director of Medical Military Institute at Central University Military Hospital The authors have found relapses of the dis- M. Duli, MD ease after 6 months from 5 –10 – 36%. From Chief nursing department, Medicine sciences Faculty, UK Tirana our experience we have not had a relapse.

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MCIF: Siemens has been a renowned industrial partner for Siemens: We have numerous X-ray units in use on ships. Expe- medical corps worldwide for decades. What is your experience riences in the American and German navies (among others) are in this special environment? unanimously positive. Of course, there are always limitations Siemens: We have been working closely together with the in terms of space and weight. You have to look very carefully to respective users and with the technical staff for a long time. which extent you can deploy these in a limited space. Military medical customers have a very high focus on quality. There is a clear trend to equip smaller vessels with medical Next to diagnostic or therapeutical quality, mechanical robust- technology, thus providing enhanced capability for improved ness is extremely important. This is, of course, especially true immediate care before evacuation to a hospital ship or a land- for mobile applications which require much more rugged based hospital. We are talking about a utilization profile which equipment than state-of-the-art hospital technology. We have is also highly interesting for civilian ships in a similar form. The extensive experience in this field, Siemens medical devices trend towards miniaturization electronics is working for us. have been in deployment for decades. In the Siemens Museum This applies for a large part of our portfolio: For laboratory you will see devices that were actually used in World War II, diagnostics as well as for imaging systems, as portable ultra- such as “Feldröntgengeräte” (Field x-ray systems). Also, there sound units and digital X-ray units with wireless detectors. This were the coach-integrated systems for mass screenings. gives us the opportunity to provide a full diagnostic spectrum We are drawing from this experience in developing new while requiring minimum valuable space. devices. Another extremely important point is logistics and transporta- MCIF: Siemens medical technology is used in military hospitals tion standardization. We are doing our utmost to bring this in as well as in deployment. Are there any special training offer- line with ISO standards. This means, for example, that our CTs ings for military personnel? are mounted in standard-size ISO containers, so that all con- Siemens: There is two-fold answer to your question. One for tainers of a field hospital meet identical transportation specifi- medical staff, and one for technical staff. As far as the medical cations. In our view, it is not feasible having, for example, a personnel is concerned, I think that top priority should be that container which is just a few centimetres larger than all other hospital equipment and field equipment should be identical or containers, which would cause great headaches to the logistics very similar, i.e. sharing the same user interface. This policy officer. assures that all medical staff is keeping a continuous high level of practice which, in turn, eliminates the need for a sepa- MCIF: What is your experience with devices that are deployed rate training for deployment. In keeping with the motto: Train on ships? as you fight. For the technical staff, we offer qualified service

28 MCIF 3/2015 engineer trainings so that technical maintenance of the devices can be guaranteed in the field. This is where the Siemens Training Centre comes in. We have a training centre that offers certified courses for medical and for technical specialists. This extends to our preparing education plans together with clients from the medical corps as well as civilian clients to the specific needs of the respective customer to ensure that the customer’s staff can be just as qualified as our own people. With these certified trainings in addition to the on-site application training we can make sure that the users can exploit the potential of their systems to their full capability. If we look at this on a higher level now, it is important for all manufacturers of hardware and electronics to also be active in CT Container for UAE Armed Forces in ZEPPELIN plant in the field of services. Hardware suppliers are increasingly being Meckenbeuren looked down on as commodity movers, while services are more and more appreciated by the markets and clients and finally In a nutshell: Our concept, especially service, international also paid for. We are entering an additional business field by service, includes various components: offering customised education plans and thus addressing the We are available; we provide our service in more than 120 client's legal obligation for continuous education of their med- countries globally. Either through Siemens subsidiaries or dis- ical staff. These solutions are currently appreciated by tributors, who were all trained to the same standard in Erlan- advanced private institutions, for whom we train technical and gen or one of our other global training centres. That's one medical personnel on site and here in our training centre point. The other point is obviously the supply of spare parts. according to an individual curriculum, and for whom we may We have central hubs for spare parts supply. More than 97 % even administer their education records as an additional serv- of our spare parts will be where they are needed the very next ice in the future. This is a trend which the German military in a day, anywhere in the world. This means that devices can be way has pioneered with us, by our having trained the German repaired very quickly once the needed parts are identified. armed forces' service engineers as Siemens-qualified engi- That’s extremely important. And then, of course, as we already neers, and who are now able to do practically anything discussed in the previous question, the training of the user’s required in terms of service and repairs for the device that is own personnel, the medical corps’ engineers. This tightly-inter- present in the field. locked service concept assures continuous and sustainable operation of our systems even under very adverse conditions. MCIF: Does that include certification? May I add something here? From our side, there are no prob- Siemens: It sure does. They are fully certified CT or X-ray serv- lems technically to also connect systems already in use to ice engineers. Of course, they already have a high standard of remote diagnostics. Meaning, a device allows prospective education when they start the system-specific training at our diagnostics. Let's take the most important consumable in com- training centre. Their receiving the training in our Siemens facil- puted tomography. That would be the X-ray tube. This can be ities gives them two equally important advantages. On one identified early on as being at risk of failure, and so at least hand, they get to know the systems inside out, with confidence from our side there would be no problem in connecting such a that this level matches the Siemens engineers’ expertise. On device that is being deployed on a ship to the diagnostics and the other hand, they also know the Siemens escalation process then be able to tell at an early stage that, watch out, it is at risk and spare part process. They know our processes. They know of failure. where our hotline is, how to talk to them and, when there really is a difficult case for once, also quickly tell them which spare MCIF: But this requires some kind of connection from the field parts are needed. directly to your company? In actual deployment this provides a huge advantage over Siemens: Right. Military security concerns are major obstacles other concepts. Some nations have completely outsourced the at the moment, but we are increasingly seeing in various coun- service of their medical devices to private companies just like tries around the world that the military is making sure that not that of many other materials. If there is a need for a service only devices located in hospitals, but also those used in the engineer in a combat zone, you will have to address security. If field, are systematically connected remotely and serviced. This the military can send one of their own people first, who come is not just about technical breakdowns. It's also about safety- "from the system", you don't have to wait for days until it's related software updates, today typically performed via remote been sorted out who is responsible for which security and how connection. We are very confident that in a few years time this can be guaranteed. We have made outstanding experi- many armed forces will have all their systems linked to this ences in this regard. We only recall one single case in remote point. Afghanistan where a Siemens service technician was flown in from a neighbouring country to assist. He then worked with the MCIF: This means, in layman's terms, so-called remote diag- personnel from the medical corps to complete the repair. nostics! So, we have our own technicians worldwide, as well as our part- Siemens: Remote diagnostics and also remote maintenance, ner' technicians, too, on the same level of qualification and they remote software updates. have to pass the same certification procedures and tests globally. This is required by Siemens as well as the supervisory MCIF: Is there an option for a replacement in case a device is authorities, be it the FDA or the Chinese SFDA or the European damaged beyond repair? authorities. In this regard, just like basically all renowned pro- Siemens: Damaged beyond repair is almost always due to ducers, we maintain an extremely high standard of quality. massive mechanical damage from a fire or a crash.

MCIF 3/2015 29 For mobile systems, it is quite straightforward: We have a maintenance float in all major countries. If there is an emergency in a hospital, we are then able to supply a loan unit or an interim machine at short notice. This is a realistic scenario. For systems permanently integrated into containers this is not a feasible solution, since you may safely assume that the container will also be a total loss. We have to rely on the respective medical corps to have reserve units available. MCIF: What do you expect further development in the area of mobile field hospitals to look like? Siemens: Well, in recent years we have seen a continuous increase in medical capabilities in mobile field hospitals. There are a few medical services here, such as the German Armed Forces, who aspire to ensure the same standard of care in deployment as for medical care domestically. This, of course, also has ramifications on the requirements in field hospitals. This means that the modalities commonly used domestically must be available in deployment, too. The other thing we're seeing here is a requirement towards reducing the footprint in- country, especially in mobile field hospitals. The smaller the space needed for the field hospital, the easier it can be securely integrated in a forward base without requiring additional forces for security. This requirement for reduced footprint is a great promoter for high-tech, since it forces the physicians to focus on equipment that is most likely to give them the munity hospital may service an area the size of half of Western best diagnosis or therapy in the shortest time with lowest Europe and they have one radiologist and one or two radiogra- space requirements. phers. They are already linked with a mother hospital located I do think that the issue of footprint is indeed a very important in Toronto or Vancouver. They work together remotely when one. Analysis of recent deployments shows that units were dis- examining patients. They just have to secure a data connec- persed over a large geographical area, so that when attempting tion. to stay compliant to the doctrine of “Platinum 10 Minutes and the Golden Hour”, flying times alone took up a large part of the MCIF: What influence do the medical services have on opera- time available. We have been witnessing a clear trend towards tionally-related device adaptation? having multiple mobile surgery facilities distributed in forward Siemens: Well, generally, the field devices are based on our bases in order to get soldiers to medical care within the time civilian devices. This way we ensure that the devices share specified. The medical device industry must be an active part- innovation cycles and they share the economy of scale. Inter- ner in these considerations. Where are the priorities? What national medical device legislation compels us to certify all our should be available in these relatively small units? In conver- products as medical devices. This way we also ensure that the sations with users we are observing a trend towards rather hav- devices meet current international standards. For established ing one large modality available, which is capable of address- standard products there is also an established logistics chain ing all medical questions, than many different ones which then for spare parts. This point is also crucial for armed forces. This again would make the installation so big that it doesn't fit into could clearly not always be guaranteed for custom-made prod- the country and security considerations anymore. ucts. The above mentioned notwithstanding, we make sure in devel- MCIF: In the field, there is not always a radiologist available. Is opment that our devices, or parts thereof, can be used in a there a chance in this regard to link the devices to remote diag- mobile environment. In the design process we consider allow- nostics in terms of telemedicine? ing for higher mechanical requirements, or offer additional Siemens: Absolutely. That's the standard today. The limiting mobile kits to meet these requirements. The combination of factor is available data bandwidth. Using the DICOM Standard these measures will permit mobile usage of these standard makes it possible to reduce data significantly, as not every devices to a large extent while retaining their status of full com- image has to be sent as a single image, but information for the pliance with medical device legislation. previous image is attached. This is called DICOM Multiframe. If we want to go one step further, today's devices also allow MCIF: Apart from purchasing devices, are there any other remote control. Of course, for safety and medical reasons, means of acquisition? there still needs to be qualified staff on site in order to position Siemens: This varies by country. We provide a wide range of patients correctly, but everything else can be done remotely. purchasing and financing options tailored to the specific situa- We need to distinguish between these two points. One being tion of the respective country. Here we stick to local legislation. the pure diagnosis of the images sent over and the other the Basically, these financing options can also be used for the mil- operation of the device, a feature we call Expert-I: The device is itary medical services. usually operated by radiographers. Now, of course, not every We're open in this regard, we have the flexibility. Every offer or radiographer can handle the entire spectrum of available appli- every procurement project requires thorough analysis of the cations, and in these cases it is possible for someone who is customer’s needs, including usage-based payment, and life- more skilled to, so to speak, guide the hand. This is already cycle and so on, and then it's surely possible to develop such a happening today, like in remote areas of Canada where a com- concept. Developing such a scenario for a mobile hospital in a

30 MCIF 3/2015 precisely what you need if you want to build a very big hospital without tying up too much capital. We are currently discussing the possibility of including operating staff in these solutions. In these discussions we have to take various legal and customer-specific limitations into account. Something we have been doing for a long time is called Inte- grated Service Management. This means there are hospitals, often very big hospitals, which leave the complete technical management of their medical devices to us. In these agreements, we take over management of the entire technical department of a hospital. This is most attractive in scenarios with a large Siemens-share in the installed base. We will also include other manufacturers’ equipment and ensure that service for this equipment is performed by qualified staff (usually the manufacturer’s staff). These management models are attractive to users or end clients because they take the complexity out of their own operations. So they can transfer the entire area of service of medical technology as a black box to us and focus their efforts on patients and medicine.

MCIF: Telemedicine is being increasingly used by medical corps world-wide. What about Siemens' technological develop- SOMATOM Emotion for UAE Armed Forces ment in this area? Siemens: We have not only seen the introduction of telemedi- combat environment with possible mass casualties could cine into practical routine in Afghanistan but also an extreme become somewhat challenging. In the civilian and stationary scenario in the Chinese earthquake of 2008 with image trans- sector where there is a continuous workload, or a usage his- fer in a disaster environment. tory, this is quite possible, yes. Sending images for remote diagnosis or a second opinion has After all, we go all the way to provider models, where we simply been standard in telemedicine for some time. Our military provide certain capabilities. Innovation cycles for the equip- users, in particular, have grown accustomed to sending images ment involved may be part of this service agreement in order to from the country of deployment to the specialist at home. They ascertain long-term sustainability. just need sufficient bandwidth for image transfer. We have All of these cases are individually tailored solutions. Let us mentioned Expert-i before that gives you the capability to assume a model scenario: There is an investor, or a govern- remotely perform procedures. The combination of these fea- ment organisation. They want to build a new hospital and tell tures has a high potential for making state-of-the-art medicine us they need a radiologist and want to perform this or that available to even the most remote locations in the field. examination there, or they may say they'll have the following Another aspect is the fact that telemedicine moves field hospi- specialist departments: cardiology, gastroenterology, neurol- tals and domestic hospitals much closer together. Thanks to ogy. Based on our experience we prepare an equipment recom- modern intensive care, even very critical patients can be evac- mendation and take this as a basis for making an offer which uated home at an early point. Telemedicine contributes greatly may include a list of devices and the respective innovation to the patient getting transferred to the most suitable medical cycles. So we may say that ultrasound units be replaced every institution at home without delay. It also ascertains that this 5 years. Or replacement of CTs is provided for every 5-7 years. institution is optimally prepared once the patient arrives. For the MRs, we assume a useful life of 8 years plus upgrade, While the concepts and some of the implementation have been so that's an extension of 50 percent, or 12 years. From this around for some years, Siemens is actively pursuing further package, we then prepare a, let's say monthly, cost schedule. steps to make these benefits even easier to use in daily routine We then expect monthly payments of an amount X. This or in extreme situations. Standardized electronic patient monthly instalment may include service, consumables and records or high-performance server structures for a web-space everything else. This is the chance to provide you with all concept for distributed reading and reporting are just some essential capabilities at a predicable cost schedule and this is examples.

About Siemens Healthcare

Siemens Healthcare is one of the world’s largest suppliers of technology to the healthcare industry and a leader in medical imaging, laboratory diagnostics and healthcare IT. All supported by a comprehensive portfolio of clinical consulting, training, and services available across the globe and tailored to customers’ needs. In fiscal 2014, Siemens Healthcare had around 43,000 employees worldwide and posted a revenue worth 11.7 billion euros, and profits of more than 2 billion euros. Further information is available on the Internet at http://www.healthcare.siemens.com/

Contact: Siemens Healthcare GmbH Henkestraße 127 91052 Erlangen

MCIF 3/2015 31 URETHRAL INJURIES

D. LIEBCHEN (GERMANY) Management of Urethral Injuries in Foreign Assignments UROLOGY SPECIAL III Urogenital trauma occurs with a rate of approximately up to 12.7% in a significant proportion of battle casualties. Up to 17% of urogenitally injured patients suffer from urethral trauma. The proportion of penetrating injuries is higher in comparison to the primarily blunt trauma in civilian patients. Urethral injuries can lead to significant morbidity when diagnosed late or left untreated. Diagnostics and therapy follow the Guidelines of the European Association of Urology (EAU) and the principles of Damage Control Surgery (DCS).

Introduction In the battles of the 20th century, a historical rate of urogenital injuries of approx. 3 % (0,4 – 4,2%) has been observed. Analysis of the Iraqi Freedom and Enduring Freedom operations between 2001 and 2008 revealed an increase in urogenital injuries to 5 % [1]. Recent data from the US Joint Theater Trauma Registry showed that these injuries were increasing in number (12.7 % in 2010) and in severity [2]. The urethra is affected in up to 17% of urogenital injuries [3]. During the Afghan conflict, the most frequent causes of injuries were from Improvised Explosive Devices (IED), mines and high-velocity bullets. Injuries caused by explosions predominate here [4]. With regard to the mechanism of injury, a dis-

tinction can be made between blunt and pen- Jordan GH, Schellhammer PF: Urethral surgery and stricture disease. In etrating traumas. Whereas among civilian patients blunt urethral trauma predominates with a percentage of approx. 90 %, the per-

Image source: Surgical Management of Urologic Diseases: An Anatomic Approach. St. Louis: Mosby 1992; 815-832. centage of penetrating trauma is higher in battle casualties. Fig. 1: Anatomy of the male urethra: (A) Fossa navicularis, (B) penile urethra, (C) bulbar urethra, (D) Urethral injuries are rarely life-threatening. How- membranous urethra, (E) prostatic urethra. ever, they can cause profound morbidity with a permanently reduced quality of life due to subsequent urethral strictures, incontinence and impo- recommended for the proximal urethra and urogenital diaphragm divides the urethra into tence. transvaginal access for the distal urethra. the anterior (penile, bulbar) and the posterior Trauma to the female urethra is rare. Often there (membranous, prostatic) urethra (Fig. 1). are concomitant injuries to the bladder, vagina Diagnosis Acute urethral trauma is suspected based on and rectum. The surgical treatment required is The male urethra comprises the penile, bul- the trauma event or the clinical picture of the performed conjointly. Transvesicular access is bar, membranous and prostatic urethra. The injury. Abnormal clinical findings that indicate

泌尿生殖系统受伤在战斗伤亡中的比例为 Le traumatisme urogénital survient à un На урогенитальные травмы прихо- El traumatismo urogenital tiene un 12.7%。有多达17％的泌尿生殖系统受伤 taux d'approximativement 12,7% dans la дится примерно до 12,7% всех боевых índice de ocurrencia de aproximada- 患者遭受了尿道创伤。穿透性受伤的比例 proportion significative des blessures du потерь. До 17% пациентов с урогени- mente hasta el 12,7 % en una propor- 高于以钝挫伤为主的平民比例。如果尿道 champ de bataille. Jusqu'à 17% des тальной травмой страдают от травмы ción significativa de víctimas de bata- 损伤延迟确诊或未经治疗，可导致发病率 patients avec blessure urogénitale souf- уретры. Доля проникающих травм llas. Hasta el 17 % de los pacientes 上升。根据欧洲泌尿外科协会（European frent de traumatisme urétral. La propor- выше по сравнению с главным обра- con lesiones urogenitales padece de Association of Urology，EAU）的指导方 tion de blessures par pénétration est plus зом тупыми травмами гражданских traumatismo uretal. La proporción de 针和损伤控制手术（Damage Control Sur- élevée que les traumatismes par contusion пациентов. Травмы уретры могут при- lesiones penetrantes es superior en gery，DCS）的原则诊断和治疗。 chez les patients civils. Les blessures uré- вести к значительному росту смертно- comparación con el traumatismo romo trales peuvent conduire à une morbidité сти в случае поздней диагностики или predominante en pacientes civiles. Las significative si elles sont diagnostiquées отсутствия лечения. В диагностике и lesiones uretrales pueden conllevar tardivement ou si elles ne sont pas trai- терапии следует выполнять рекомен- morbilidades significativas cuando se tées. Le diagnostic et la thérapie suivent дации Европейской ассоциации уроло- diagnostican tarde o se dejan sin tratar. les recommandations de l'Association гов (EAU) и принципов многоэтапного Los diagnósticos y terapias siguen las Européenne d'Urologie (EAU) et les prin- хирургического лечения (DCS). Directrices de la Asociación Europea de cipes de la Chirurgie avec Damage Control Urología (AEU) y los principios de la (DCS). Cirugía de Control de Daños (CDD).

32 MCIF 3/2015 Degree Description Recommended management 1 Elongation of the urethra No therapy without extravasation on the RUG 2 Contusion, blood-stained discharge Conservative, suprapubic from the meatus, no extravasation catheter or indwelling catheter on the RUG 3 Partial interruption of the urethra with extravasation into the injured area,

the urethra and/or bladder are seen UROLOGY SPECIAL III SPECIAL UROLOGY proximal to this 4 Complete interruption of the urethra with SPC and delayed treatment extravasation into the injured area, or endoscopic realignment

the urethra and/or bladder are not seen ± delayed treatment Hamburg Military Hospital – Radiology archives, proximal to this 5 Complete or partial interruption of Primary open surgery required

the posterior urethra with tear to the neck Image source: individual patients of the bladder, rectum or vagina, extravasation into the area of the injury. Fig. 2: RUG following a sub-total tear of the bulbar urethra secondary to blunt perineal Tab. 1: EAU classification of blunt urethral injuries trauma (grade 4 trauma). further diagnostic investigations are, for thral injuries and in more than 75 % of the affected portion of the urethra and the example, blood-stained discharge from the injuries to the anterior urethra [5]. The degree extent of the injury. Urethral trauma can be meatus, a raised prostate gland during the of haematuria does not correlate with the classified based on the x-ray image (Table 1). digital rectal examination as well as severity of injury. The injured area is visualised by the extrava- haematomas on the penis, scrotum and per- The retrograde urethrogram (RUG) is the sation of contrast medium. With grade 1 and ineum. Blood-stained discharge from the examination method of choice for diagnosing grade 2 injuries, the urethral mucosa is intact meatus occurs in 37 – 93 % of posterior ure- and evaluating urethral trauma. This shows and a transurethral catheter can be intro-

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MCIF 3/2015 33 duced. With trauma to the posterior urethra tially performed to drain the urine. To restore the objective of which is to stabilise severely with no visualisation of the bladder on the urethral continuity, the therapy options are injured patients sometimes at risk of bleeding urethrogram, a cystogram must be performed primary realignment and urethroplasty. If by minimising the need for an additional sur- via a suprapubic cystostomy to rule out any immediate surgical exploration is not indi- gical trauma. injury to the bladder neck. cated, primary realignment can be carried out Therefore the initial objective in the case of following stabilisation of patients with often urethral trauma is to establish reliable urine Therapy multiple injuries. During the preferred endo- drainage. If a retrograde urethrogram cannot Detailed guidelines from the European Asso- scopic procedures, it is important to preserve be performed in this context, suprapubic ciation of Urology (EAU) on the treatment of the bladder neck since this is often the only urine drainage is the most reliable and effec-

UROLOGY SPECIAL III urethral trauma were last updated in 2010 [5]. remaining functional sphincter mechanism. tive procedure. X-ray diagnostics by means of Primary open realignment is only indicated if a retrograde urethrogram and, if necessary, a Anterior urethral trauma an abdominal or pelvic surgical procedure is cystogram can be conducted during the sta- A suprapubic bladder catheter (SPC) or a required as a result of other injuries, as well bilisation phase. As part of the scheduled transurethral catheter (DC) can be inserted in as in the case of trauma to the bladder neck repeated surgeries carried out on haemody- the event of blunt partial trauma to the anterior or rectum. The decision for realignment is namically and metabolically stable patients, urethra. By using a suprapubic urine drain, fur- influenced by concomitant injuries. These can the required initial urological treatment takes ther urethral trauma caused by catheter manip- make lengthy anaesthesia or lithotomy posi- place depending on the findings and on the ulation can be avoided. If there is complete tioning impossible. Endoscopic realignment basis of the previously described criteria. If break in urethral continuity (Fig. 2), in addition is usually performed within 7 days of the definitive plastic surgery is required, this to inserting a suprapubic drain, an attempt can patient being stabilised and should be pre- takes place in the patient's country of origin be made to perform primary endoscopic ferred because of lower morbidity. This proce- after an interval of 3 – 6 months. Complex ure- realignment. After an interval of 4 weeks, heal- dure can be performed retrogradely and ante- thral trauma, especially to the posterior ure- ing is reviewed via a micturating cystourethro- gradely/retrogradely via the cystostomy thra with possible involvement of the bladder gram (MCUG). The urine drain can be removed channel. The advantage of the realignment neck, is a major challenge for urologists when if the urethra is intact. A subsequent urethral procedure compared to suprapubic urine treating these kinds of battle injuries. In addi- stricture develops in approx. 50% of cases [6]. drainage alone is the lower rate of stricture tion to profound endoscopic skills, pelvic sur- Endoscopic and open reconstructive proce- (64 % vs 100 %). However, in two-thirds of gery and plastic reconstructive procedures dures can be used depending on the findings. cases, a second procedure is necessary. Both must therefore be an integral part of surgical Penetrating complete or partial traumas to the endoscopic therapy and plastic reconstruc- training. n anterior urethra require extensive surgical tion are technically more simple following exploratory investigations. In addition to successful realignment. debridement and the removal of foreign bod- Immediate primary urethroplasty to treat pos- AUTHOR ies, primary suturing is considered in partial terior urethral trauma is not recommended. defects and end-to-end anastomosis in com- The functional results (21 % incontinence, Lieutenant plete ruptures. Primary anastomosis is not 56 % impotence, 49 % stricture) are not con- Colonel MC, recommended in extensive injuries with clusive due to the view being markedly Dr Dirk defects of over 1.5 cm. In this incidence the restricted by the extensive tissue trauma [8]. Liebchen ends of the urethras are marsupialised, i.e. Delayed primary urethroplasty within 2 weeks sutured to the skin in the form of a urethros- of haemodynamic and metabolic stabilisation 1997–2003 Degree course in human tomy and a suprapubic urine drain is inserted. of the injured person is predominantly used in medicine at the Ernst-Moritz-Arndt Univer- Grafting procedures do not play a part in the case of female urethral rupture. sity Greifswald acute treatment. Plastic reconstructive sur- 2003 Degree in the study of medicine and gery is performed for large defects following Plastic reconstruction medical licence an interval of at least 3 months. The gold standard of plastic urethral recon- 2004 Doctorate struction is delayed urethroplasty after 3 – 6 2004–2005, 2007–2010 Residency at the Posterior urethral trauma months. The often severe concomitant injuries Department of Urology, German Armed Forces Hospital, Hamburg (Doctor in A distinction is made between partial and have healed after this period. The functional charge OTA Dr. Wagner) complete disruption of the continuity of the results in relation to restricture rate, impo- 2005–2007 Military physician Husum urethra in the case of injuries to the posterior tence and continence are better compared to medical centre urethra. A complete disruption of continuity immediate reconstruction. This surgery is usu- 2010 Certification as urologist can occur in severe pelvic fractures. Erectile ally performed as a one-stage procedure via since 2011 Senior physician of Depart- dysfunction occurs in 20 – 60% of patients perineal access. After resection, end-to-end ment of Urology, German Armed Forces with complete rupture of the posterior ure- anastomosis is used for short segment stric- Hospital, Hamburg thra. The probability is determined by the tures. To treat longer strictures, free grafts (e.g. severity of the initial trauma [5]. buccal mucosal grafts) are used for urethral Address of the author: Partial traumas to the posterior urethra are augmentation. OFA Dr. med. Dirk Liebchen initially treated by performing a suprapubic Medical specialist for urology cystostomy. After an interval of 3 weeks, heal- Conclusions Senior physician ing is reviewed on an X-ray. If a stricture Urethral trauma can occur in both injuries to Hamburg Military Hospital develops, endoscopic and plastic reconstruc- the external genitalia and to pelvic region. The Department of urology tive procedures can be carried out depending concept of Damage Control Surgery has been Lesserstrasse 180, 22049 Hamburg on the findings. used successfully for many years in the treat- E-mail: [email protected] In the case of complete trauma to the poste- ment of battle casualties with multiple Tel.: 040694721280 rior urethra, a suprapubic cystostomy is ini- injuries. This describes a surgical approach,

34 MCIF 3/2015 GENITAL INJURIES

A. MARTINSCHEK, M. HÖPPNER, C. SPARWASSER (GERMANY) Management of Genital Injuries – from Trauma to Reconstruction

Penile and scrotal trauma are rarely life-threatening injuries, however very often associated with a III SPECIAL UROLOGY loss of erectile respectively micturition function and/or fertility. In the initial phase of treatment, a safe urinary diversion is mandatory. The real dimension of genital trauma especially from battlefield injuries in most cases can be determined by surgical exploration only. The restoration of sexual function and micturition may require repeated and very complex reconstructive surgery.

Introduction The reason for the comparative increase in Isolated injuries to the external genitalia are Within the context of military conflicts, the injuries to the testes, scrotum, penis and ure- rarely life threatening. However, they are often incidence rate of urogenital injuries is thra is the wearing of flak jackets, which cover associated with a loss of sexual function, fer- reported as 2.9 – 12.7% [1 – 5]. the kidneys, ureter and bladder, but which do tility or continence and micturition function Injuries to the external genitalia represent the not offer adequate protection to the external and are often disfiguring. majority of urogenital injuries, and studies genital region. Many soldiers do not want to available indicate that their frequency has wear the flak jacket's groin protector because Scrotal and testicular trauma increased in relative terms over the years it severely restricts movement. Injuries to the scrotum or testes represent the (Table 1). Gunshot wounds to the external geni- Another reason is the widespread increase in majority of injuries to the external genitalia talia from modern high-velocity bullets (e.g. AK attacks using “Improvised Explosive Devices” (up to 72.7 %) [1, 7, 9]. They occur as a blunt 47, G36, NATO M14 or U.S. M16A2 with muzzle (IEDs), which are characteristic of the or penetrating trauma. This can result in scro- velocities of 700 – 1000 m/s) are, similar to Afghanistan conflict in particular [2, 8]. The tal lacerations, scrotal haematomas, haema- other injury areas, often more extensive than upward blast causes injury to the lower limbs toceles or hydroceles (Figures 1 and 2). those from civilian sporting weapons or pistols and the external genitalia. Even with correctly Likewise, testicular ruptures occur due to direct (muzzle velocities of 90 – 380 m/s). This is worn genital protection, the effect of the protec- or indirect trauma (rupture of the tunica albug- clearly apparent from the markedly different tion is limited [2, 9]. Besides injuries to the exter- inea with approx. 50 kg pressure, e.g. against orchidectomy rates in cases of bullet wounds nal genitalia, urogenital injuries also include fre- the inferior public ramus) or complete testicu- to the testes (62 % for sporting weapons vs. quent fractures and injuries to the femoral lar avulsion, e.g. following injuries caused by 90 % for high-velocity firearms) [6, 7]. region. Table 2 shows a detailed list [9, 10]. being run over. (Figures 3 and 4). Testicular tor-

Fig.1 and 2: post-traumatic development of a hydrocele of the right testis following an IED attack on an ENOK II. Presentation of the vehicle passenger 3 months after a blunt scrotal trauma due to the impracticality of wearing personal protective equipment when travelling in the vehicle.

阴茎及阴囊外伤是一种很少危及生命的伤 Les traumatismes du pénis et du scrotum Травмы полового члена и мошонки Los traumatismos de pene y escroto 害，但是往往与丧失勃起功能以及排尿功 sont rarement mortels, toutefois ils sont редко несут угрозу жизни, однако, rara vez son lesiones que pongan en 能和/或生育能力相关。在治疗的最初阶段 très souvent associés à des troubles de очень часто связаны с потерей эрек- peligro la vida, sin embargo, muy a ，必须进行安全尿路改道。在大多数情况 l'érection, de la miction urinaire et/ou à la тильной функции и функцией мочеис- menudo se asocian con una pérdida de 下，生殖器外伤（特别是战场受伤）仅可 fertilité. Dans la phase initiale du traite- пускания и/или фертильности. В las funciones eréctil, de micción y/o 以通过手术探查确定。恢复性功能和排尿 ment, une dérivation urinaire saine est начальной фазе лечения, безопасное fertilidad respectivamente. En la fase 功能可能需要重复进行非常复杂的重建手 obligatoire. Dans la plupart des cas, отведение мочи является обязатель- inicial del tratamiento, es obligatorio 术。 l'étendu du traumatisme génital lors de ной мерой. Реальный масштаб травмы practicar una desviación urinaria blessures sur le champ de bataille ne peut половых органов, особенно травм на segura. La dimensión real del trauma- être déterminée que par l'exploration chi- поле боя в большинстве случаев tismo genital, especialmente de lesio- rurgicale. La réhabilitation des fonctions может быть определен лишь в ходе nes del campo de batalla, en la mayo- sexuelle et urinaire peut exiger de mul- хирургического вмешательства. Для ría de los casos puede determinarse tiple et très complexes interventions de восстановления половой функции и únicamente mediante exploración qui- chirurgie réparatrice. мочеиспускания может потребоваться rúrgica. La restauración de la función повторная и очень сложная операция sexual y de la micción pueden requerir реконструктивной хирургии. una cirugía reconstructiva repetida y compleja.

MCIF 3/2015 35 36 UROLOGY SPECIAL III sue injuriesin the areaofscrotumand 18]. Wherethere aremoreextensivesofttis- – %ofcases[7, affects bothtestesin8 30 tions [2].Penetratingscrotal trauma also – 3 mmscrotallacera- lar rupturewithonly2 Waxman etal.oftennotedacomplete testicu- extent ofthetrauma. tal injury,inordertobeable assessthe especially, irrespectiveofthedegreescro- be investigatedsurgicallyinamilitarysetting lar trauma.Penetratingscrotalinjuriesmust a reliablepredictorofthepresencetesticu- In general,thevisualclinicalfindingsarenot perfusion ofthe(residual)testiculartissue. provide usefulinformationinrelationtothe Doppler duplexultrasounddiagnosticscan %[7,17].However,colour operatively of56 ular rupturewithanaccuracyverifiedintra- same appliestothedifferentiationofatestic- %),the %)andsensitivity(28 specificity (78 %,otherstudiesrevealamuchlower 98.6 Some studiesreportspecificitiesofupto examination isthesubjectofcontroversy. However, thereliabilityofultrasound – 16]. lar rupturemustbeassumed[3,7,13 patterns followingtesticulartrauma,atesticu- pattern. Wherethereareheterogeneousecho the tunicaalbugineaandparenchymal loss oftheovalshape,anapparentbreakin assessing theintegrityofscrotumis inflammations. Themostimportantcriteriafor Doppler ultrasound)orsecondarytesticular sible torsion(usingacolourorpulsed haematoma, haematoceles,hydroceles,pos- of intra-testicularand/orextra-testicular the scrotalcontentscanbeassessedinterms lution ultrasound(7.5MHzprobeorgreater) ment forscrotalinjuries.Byusingahigh-reso- sensitive andmostpreciseimagingassess- of theinjuredscrotumisuptonowmost ticular palpation,anultrasoundexamination In additiontotheclinicalassessmentandtes- groin. right the to matic consequentialinjuries[7,11,12]. trauma sions ordislocationsarealsocommontrau- vascular and over run being after avulsion Testicular 4: and 3 Figures Access via the inguinal incisions to correctly identify the testicular artery and ligature on the on ligature and artery testicular the identify correctly to incisions inguinal the via Access internal inguinal ring where no amputations have been performed). been have amputations no where ring inguinal internal serve thetesticulartissueiffertilityand sue mustbeavoided[20].Itiscrucialtopre- * Testicular injuries are subsumed under scrotal injuries scrotal under subsumed are injuries Testicular * trafluoroethylene Gore-Tex introduction offoreignmaterial(e.g.polyte- can beusedtocoverthedefect[2,7,20].The inea isextensive,afreetunicavaginalisflap 3.0). Wheredestructionofthetunicaalbug- out usingabsorbablesutures(e.g.Vicryl intact testiculartissue.Thisisusuallycarried albuginea shouldbeattemptedoverthe extent ofthetrauma.Closuretunica tum canbecarriedoutdependingonthe Primary reconstructionofthetestesandscro- [3, 7,12,19]. tal andthepatient'ssymptomsareminor hematoceles requiresashorterstayinhospi- tubules mustbeevacuated.Evacuationof and theblood,haematomasnecrotic The deadtissuemustbecarefullydebrided %)[9]. frequently performedoperations(40.4 injuries tothepenisorscrotumweremost debridement andtreatmentofsofttissue A studybyHudakrevealedthatexploration, avoid anorchidectomyatalaterstage[3,12]. exposure andreconstructivesurgery[25]to catheter. Testicularrupturerequiresearly urine shouldbedrainedviaasuprapubic also beconsidered(seepeniletrauma)and testes, traumatothebulbarurethrashould Tab. 1: Relative frequency of urogenital injuries in different conflicts (adapter from [1] ), Figures in %. in Figures ), [1] from (adapter conflicts different in injuries urogenital of frequency Relative 1: Tab. # Testicular and penile injuries are subsumed under scrotal injuries scrotal under subsumed are injuries penile and Testicular # ei .61811. # # 30.0 11.6 32.8 18.5 * 40.0 15.0 10.4 3.3 22.7 19.1 8.1 12.0 17.2 5.2 * 39.6 4.26.1 19.4 9.112.2 4.6 13.3 29.0 7.8 Penis 0.817.3 29.6 Testes 21.3 2.72.0 Scrotum 22.9 Urethra 2 Bladder Vietnam Ureter BosniaandCroatia Iraqi Freedom Kidney ISAF/EF Wounded organ ® ) intoinfectedtis- ® of 20testis-preservingsurgeriesand Data fromBosnia-Herzegovinarevealsasplit %ratewasstated[18]. Phonsombat, a51 ticular trauma[23,25],ina30-yearreviewby %testicularpreservationfollowingtes- over 45 [20]. Ina10-yearreview,Brandesreported tion orbymeansofatunicavaginalispatch could notbeclosedagainviaprimaryinten- of 17testicleswerenon-viable,9out11 (sporting weapons,civilianenvironment)6out In astudyongunshottraumatothetesticles %ofcases. tents canbepreservedinupto64 mobility ofthetestesmeansthattheircon- injuries causedbyconventionalfirearms,the testicular avulsion[12,24].Withgunshot trauma cases,eveniftherehasbeencomplete %ofblunt Preservation ispossibleinover90 and flapplasty. reconstructions [7,23]includingmeshgrafting often requirescomplexandrepeatedsurgical caused byIEDs,theextensivelossoftissue attached tothescrotum.[7,22].Withinjuries isation, evenifthelaceratedskinisminimally tal skindefectcanoftenbeachievedbymobil- elasticity ofthescrotum,coveragescro- acceptable iscertaincases[2,7].Duetothe wounds. Primaryclosureusingadrainisonly uum bandagesareessentialforinfected debridement, openwoundtreatmentorvac- agement bywoundlavageandrepeated should beadministered[7].Localwoundman- checked and,ifnecessary,boosterinjections It isobligatorythatthevaccinationstatus although thereislittledatatosupportthis.[7]. mended followingpenetratingscrotaltrauma, Prophylactic antibiotictreatmentisrecom- struction appearsnottobepossible[3,7]. destruction ofthetestes,iftesticularrecon- unstable conditionorinthecaseofcomplete orchidectomy isindicatedforpatientsinan cases ofthishavebeendescribed[7,21].An following rehabilitation,evenifonlyafew two-stage vasovasostomycanbeattempted is surgicallypossible[7,21].Amicrosurgical out avasovasostomycanbeattempted,ifthis spermatic cord,reconstructivesurgerywith- In theeventofcompletedisruption served. normal endocrinefunctionaretobepre- nd MC World War IF 3/2015 UROLOGY SPECIAL III SPECIAL UROLOGY

Figures 5 to 7: Coverage of a large area of genital (and abdominal) soft tissue damage (Fournier's gangrene here) using a mesh graft on the abdomen and a non-meshed split-skin graft on the penile shaft.

Figures 8 to 10: Reconstruction of the external genitalia by performing a thigh and perineal skin flap plasty following subcutaneous displacement of the testes to thigh pockets.

28 orchidectomies in the case of 48 scrotal high-velocity bullets. Penile trauma often injuries to the penis, the possibility of dis- injuries, most of which were caused by explo- presents itself as an extensive injury to the persed foreign bodies and infectious material sions [10]. In a study by Hudak (military set- genital skin and soft tissue. must always be considered [7, 22, 25, 29]. In ting) involving 88 gunshot or blast injuries to In penile trauma, it must always be borne in most cases, urine is drained via a suprapubic the testicles, 45 (51.1 %) of the testicles were mind that the urethra may be affected. In pen- catheter. Even with extensive injuries, recon- preserved [23]. Further military studies show a etrating trauma, literature cites urethral nection of larger parts of the penis is possible testicular preservation rate of 30 – 39% [9, involvement in 11 to 29 % of cases [6, 18, 25]. due to the good blood supply. In the case of 26], thus a slightly lower preservation rate Telltale clinical findings are bloodstained dis- complete traumatic penis amputations, must be expected in the military environment charge from the urethra (in 37 – 93% of pos- reanastomosis can be attempted within the than in the civilian environment. With injuries terior and 75 % of anterior urethral trauma), first 24 hours [12, 22]. caused by high-velocity projectiles, testicular macrohaematuria or anuria; these symptoms In a larger number of civilian gunshot injuries loss is expected in up to 90 % of all cases [24]. may not be present despite the existence of to the penis (n = 43), a careful surgical If it is not feasible to perform reconstructive urogenital trauma. The fact that a trans-ure- exploratory investigation was carried out in surgery of the testes, TESE mapping (testicular thral catheter was inserted as first-aid treat- 95.3 % of cases, a conservative procedure sperm extraction) or a MESA (microsurgical ment at the site of the incident and urine is was only opted for where there were obvious epididymal sperm aspiration) can be carried running through it does not rule out signifi- superficial defects. In 90.2 % of cases, there out on the removed testes to extract sperm for cant urogenital trauma [12, 28]. A retrograde was trauma to the corpora cavernosa, in the purposes of later fertilisation [24]. Sperm urethrogram must be performed if a urethral 34.1 % injury to the urethra and in 24.4 % an extraction from the ablated testicles is also trauma is suspected and in all cases of pene- additional injury to the testes [30]. A military possible after testicular amputation (as close trating trauma; trans-urethral manipulation study revealed injuries to the corpora caver- to the event as possible). The contents from should not be performed until such trauma nosa or urethra in approximately half of all the epididymides and vas deferens can be has been ruled out [3, 7]. penile traumas. These injuries were diag- transferred into an appropriate medium and Injury to the corpus cavernosum occurs in nosed by retrograde urethrogram, cystoscopy used for artificial insemination [5, 27]. penetrating traumas in 50 % to 90 % of cases. and/or surgical exploration with penile de- Since an appropriate diagnostic examination gloving. Corporal defects were closed immedi- Penile trauma (MRI) is not available to use and the full ately, where possible. In a study, 46 % of Trauma to the penis and urethra account for extent of the injury cannot always be patients with gunshot or blast injuries to the 26.3 % of the injuries to external genitalia. assessed, a surgical exploratory investigation penis required penoplasty and/or corpo- The main causes of trauma in this respect can of the findings and excision of the necrosed raplasty compared to 54 % who underwent be both improvised explosive devices and tissue is mandatory. With gunshot or blast debridement treatment or received superficial

MCIF 3/2015 37 38 UROLOGY SPECIAL III can alsobeused. dermoplasty (withadequatebloodsupply) ment isrequiredatalaterstage,pedicleflap in caseswheresubsequentprosthetictreat- injuries, iftheinjuryaffectsdeepertissuesor grafts [7].Wherethereareveryextensive full injurypatternandanyothernecessary buttocks, thighsoraxilla,orientatedtothe The graftscanbetakenfromtheabdomen, ual intercourse(Fig.5)[7,32]. coverage oncethepatientrecommencessex- with lessscarringandoffermoreresistant penile shaftproduceabettercosmeticresult tion [7,22].Full-thicknessskingraftsonthe 0.4 mminordertoreducetheriskofcontrac- split-skin graftswithathicknessofatleast here [7].McAninchetal.recommendusing graft; meshedsplit-skinmustnotbeused penile shaftduetothecontractureof age overall,butmustnotbeusedonthe A meshsplit-skingraftprovidesgoodcover- 46.3% ofallurologicalprocedures[23]. often repetitiveproceduresrepresent44.9to to astudybyHudak,theselaboriousand graft coverageisoftennecessary.According measures suchasvacuumbandagesormesh extensive, theuseofwoundmanagement the genitalskin[7].Wheretraumaismore is ofteneasytocoverduetheelasticityof [7]. Thelossofasmallareathepenileskin left and,ifpossible,removedatalaterstage tions oftissuedoubtfulviabilitymustbe much viabletissueaspossible;thusanypor- ment ofnecrotictissueandpreservationas main treatmentmeasuresarethedebride- and theremovalofanyforeignbodies, In additiontohaemostasis,urinedrainage follow-up data[3,9]. was onlyasmallnumberofcasesandlittle tence followingpeniletrauma,althoughthere %andimpo- penis curvaturerateofover50 (Bosnia-Herzegovina, USmilitary)revealsa [24, 31].Datafromthemilitaryenvironment % ment, thepost-therapeuticvirilityrateis80 whereas withimmediateandtherighttreat- erectile dysfunctionandpeniscurvature, is inadequate,thereahighriskofboth means ofplasticreconstruction.Iftreatment mis, venousorpericardialpatchgraftsby Extensive defectsmustbecoveredwithder- cleansing. rupted suturesfollowingappropriatewound cavernosa canbeclosedusingsimpleinter- fractures, moreminorinjuriestothecorpora wound management[23].Similartopenile urological measures istomaintainurinary injuries), theprimary objectiveoftheinitial surgical stage(inthecaseoflife-threatening tion orfertility.Attheresuscitation andinitial ated withalossofsexualormicturition func- threatening, howevertheyare often associ- Trauma toexternalgenitaliaare rarelylife- Summary function. Thisisusuallycomplexand,gener- way forthelaterrestorationofurological exploratory investigation.Thisalsopavesthe deployment country,bymeansofan often onlybedetermined,inparticularthe drainage. Theextentofurogenitalinjuriescan Table 2: Frequency of concomitant injured organs in urogenital injuries (from [10]). (from injuries urogenital in organs injured concomitant of Frequency 2: Table ie 72-111 3 - 1 3 1 1 1 1 - 1 - 2 1 1 17 Scrotum Penis 25 14 Urethra Urinary Liver Diaphragm Ureter Chest Kidney Injured organ eiem--3213 21 2 1 - 7 - - 18 2 - 4 - 3 1 - 4 8 3 - - 5 2 - 12 2 1 - 5 - 1 - 1 - 3 - 12 1 - - - 1 1 12 6 5 - 5 1 8 - - 2 4 Perineum 21 - - 2 Buttocks 2 Thigh 2 21 Vena cava 8 2 8 Fractures Pancreas 8 Small intestine 5 Colon Spleen Stomach Duodenum M. Höppner,E.Sparwasser CO-AUTHORS First andcorrespondingauthor E-mail: [email protected] Oberer Eselsberg40,D-89081Ulm (Germany) Department ofUrologyMilitaryhospital ofUlm Lieutenant ColonelAndreasMartinschek,MD Address oftheauthor: 2013 2011 2008 2005 2004 2004 Deployment abroad: Specialty: Germany 2011 – 2011 as Urologist,Stuttgart,Germany 2010 2009 – 2004 2006 2003 – 2009 2006 – 2003, 2002 – 2001 2000 – 2000 1995 – 1994 1993 Medical andmilitarydevelopement: Lieutenant ColonelDrAndreasMartinschek AUTHORS ISAF, Afghanistan,Urologist,Fieldhospital,Mazar-e-Sharif ISAF, Afghanistan,Urologist,Fieldhospital,Mazar-e-Sharif ISAF, Afghanistan,Emergencydoctor,MedEvac,Mazar-e-Sharif KFOR, Kosovo,EmergencydoctorAirMedEvac,Toplicane KFOR, Kosovo,EmergencydoctorMedEvac,Prizren ISAF, Afghanistan,EmergencydoctorMedEvac,Kunduz Accreditation offellowtheEuropeanBoardUrology,Brussels,Belgium Accreditation asemergencymedicinespecialist,Munich,Germany Military medicaleducation,Germany Basic militaryservice,Kaufbeuren,Germany today SeniorphysicianinUrology,DepartmentofMilitaryhospitalUlm, Urooncology, Reconstructivesurgery,Roboticsurgery Department ofUrology,UniversityMannheim,Germany12/2010Accreditation General practicioner,AirforcebasePenzing,Germany Department ofSurgery,MilitaryhospitalUlm,Germany Study ofmedicineatUniversityUlm,Germany n 5 n )badr n=9 n=1)(n=44) (n=16) (n=9) bladder (n=6) (n= 65) Department ofUrology.MilitaryhospitalUlm,Germany (n= 23) Image sources: sources: Image Hospital (withtheconsentofpatient) Lieutenant ColonelDr.Martinschek,UlmMilitary well asextensivereconstructivesurgery. ally speaking,requiresstagedproceduresas MC IF 3/2015 NATO CENTRE OF EXCELLENCE FOR MILITARY MEDICINE (MILMED COE)

NATO Centre of Excellence for Military Medicine (MILMED COE)

Main events in the second half of 2015

3 –5 November 2015 About DH Function nd MILMED COE was nominated by ACT Joint Force Trainer (JFT) to 2 NATO Medical Lessons Learned be the Department Head (DH) for the NATO Medical Support Workshop in Hamburg, Germany (Med Sup) Discipline. This appointment was approved by the MILMED COE will conduct the 2nd NATO Medical Lessons North Atlantic Council (NAC) on 25 June 2015. The primary Learned Workshop (WS) at the Führungsakademie der duty of the DH is to translate NATO operational requirements Bundeswehr (Bundewehr Staff College) in Hamburg, Ger- into education and training (E&T) solutions within the disci- many from 3 to 5 November 2015. The WS, which is open pline framework. to all Organisations and Subject Matter Experts, is sup- Specifically, the DH for Med Sup E&T is responsible for match- ported by the Committee of the Chiefs of Military Medical ing the requirements with E&T solutions and for the coordina- Services (COMEDS). The aim of the workshop is to tion of those solutions. The DH will strive to ensure that the analyse the implications of Hybrid Warfare and Future Arti- solutions identified are delivered in the most effective, effi- cle V Missions for the Concept of NATO Medical Support. cient, and affordable manner through NATO Allies, Partners, Specifically the goal is to have WS participants determine and Non-NATO Entities (NNE). Additionally, the DH will con- which regulations need to be optimized or modified in duct the Annual Discipline Conference (ADC), with participation light of the current geopolitical situation and current NATO from the community of interest, the Requirements Authority planning. (SHAPE/ACO JMED/MEDAD), Subject Matter Experts (SME), E&T institutions and affiliated organisations and produce a Disci- For further information, please visit our website pline Alignment Plan (DAP). The DAP will reflect the main www.coemed.org or contact the Lessons Learned Branch developments and achievements and outline the way ahead, at [email protected]. concerning NATO Med Sup E&T, as well as highlight the contributions to the MED Sup E&T by partners and NNE.

11–13 November 2015 Medical Support Education and Training Annual Discipline Conference in Budapest, Hungary MILMED COE as the proposed Department Head (DH) for Medical Support is organizing the Medical Support Educa- tion and Training Annual Discipline Conference (ADC) on 11-13 November 2015 held in Budapest, Hungary. The primary aim of the conference is information exchange and sharing among NATO and Allies, to synchronize the development strategies and directions of the individual trainings, and analyse the current status and way ahead for military medical training. This will be determined by first reviewing the current training requirement as defined by NATO Allied Command Operations, revise NATO/national NATO MILMED COE Postal Address training opportunities, recognize gaps, and propose solu- NATO Centre of Excellence for Military Medicine tions. The final product of the ADC will be the Medical H-1555, Budapest Support Discipline Alignment Plan. P.O.B.: 66 HUNGARY For further information, please visit our website www.coemed.org. E-mail: [email protected] POC: CAPT (OF5) Kimberly FERLAND, Phone: +36 1 883 0100 [email protected] or phone +36-1-883-0110 Fax: +36 1 883 0127

MCIF 3/2015 39 CANADIAN ARMED FORCES MEDICAL RISK MATRIX

C.H.T. CROSS (CANADA) Canadian Armed Forces Medical Risk Matrix

From the CAF perspective, a stratified risk matrix was formulated by the Directorate of Medical Policy/Medical Standards, which balanced an acceptable level of risk to the health and safety of CAF personnel, whilst taking into consideration the potential unavailability of an appropriate level of medical care required, due to operational situation. The following article explains history and format of this matrix.

Introduction “soldier first” principle and require an ability medical fitness of CAF member’s with com- The mission of the Department of National to fulfill 6 common “bone fide occupational plex medical conditions should be consid- Defence and the Canadian Armed Forces (CAF) requirement” physical tasks and also to per- ered. This decision in part was related to the is to defend Canada and North America, their form duties whilst deployed. The latter number of personnel who were being interests and values, while contributing to requirement include an ability to perform released and also influenced by the opera- international peace and security. In order to duties in a variety of geographical locations tional tempo requirements at the time, which meet these mission requirements, the CAF is and climatic conditions in any physical envi- was primarily focussed on the conflict in given broad authority and latitude in utilizing ronment, to deploy on short notice, to sustain Afghanistan. CAF members, for which Section 33 (1) of the irregular or prolonged working hours, ability National Defence Act is the statutory basis to tolerate irregular or limited meals, travel as Medical Risk Matrix (1). The Act states that “The Regular Force, all a passenger in any mode of transportation, From review of the medical literature at that units and other elements thereof and all offi- perform duties under physical and mental time, it was recognized that some organiza- cers and non-commissioned members thereof stress, to perform duties with minimal or no tions were already utilizing a risk matrix strat- are at all times liable to perform any lawful medical support and also perform effectively ification concept; this encompassed the prob- duty”. Section 33 (2) has similar requirements without critical medication (4). ability of a medical condition recurring or for the Reserve Force. This statutory require- For those personnel who are unable to meet exacerbating and the consequences of such ment is the legal foundation for the Universal- the generic tasks of Universality of Service, an event, to include the requirement, type ity of Service principle, which states that “CAF they will likely be released from the CAF, for and degree of medical intervention required. members are liable to perform general mili- which a decision is determined by the Direc- This risk stratification concept was originally tary duties and common defence and security torate of Military Career Administration developed from an engineering perspective duties, not just the duties of their military (DMCA), a non-medical CAF organization. and was subsequently further developed as a occupation or occupational specification. This tool and guidance for aeromedical decision- may include, but is not limited to, the require- Determination making related to astronauts who were being ment to be physically fit, employable and of Medical Fitness screened for International Space Station (ISS) deployable for general operational duties” Medical fitness of personnel is determined by duties. Similar risk matrices were developed (2). Canadian Forces Health Services physicians, for civil aviation and also for utilization by the utilizing occupational medicine principles CAF Aerospace and Undersea Medicine Board. Generic Task Statements and the CAF Medical Standards. The Direc- Civil Aviation originally utilized a risk of 1 % These specific requirements of physical fit- torate of Medical Policy/Medical Standards, per year, for which the probability of a cata- ness, employability and deployability are cod- has the delegated authority on behalf of the strophic medical event being less or equal to ified in the Defence Administrative Orders and Surgeon General, to assign permanent this value, would be deemed unlikely to Directives (DAOD) 5023-0 and 5023-1 (3), change of medical employment limitations occur. These probabilities were further modi- which define minimum operational standards, and medical category, in a fair and consistent fied, dependent on the type of medical event for which all CAF personnel are expected to manner. In 2008, it was recognized that a and now utilize a risk tolerance of up to 2 % meet. These generic tasks are based on the change in approach regards assessment of per year (20% per 10 year period).

从CAF的角度来看，医疗政策/医疗标准理 Du point de vue des Forces Armées Cana- С точки зрения CAF, стратифицирован- Desde la perspectiva de la CAF; se for- 事会（Directorate of Medical Policy/Med- diennes (CAF) une matrice stratifiée des ная матрица рисков была сформулиро- muló una matriz de riesgos estratifi- ical Standards）制定的分层风险矩阵平衡 risques a été formalisée par la Direction вана Дирекцией по медицинской поли- cada por la Junta Directiva de Política 了CAF人员的健康和安全可接受风险水平 de la Politique Médicale/Standards Médi- тике / медицинским стандартам, в Médica/Normas Médicas, equilibrando ，同时考虑到由于操作情况导致的所需适 caux, qui harmonise un niveau acceptable которых был сбалансирован приемле- un nivel aceptable de riesgo para la 当水平医疗护理的潜在不可获得性。下文 de risques pour la santé et la sécurité des мый уровень риска для здоровья и без- salud y la seguridad del personal de la 解释了该矩阵的历史和格式。 personnels des CAF, tout en tenant опасности персонала CAF, а также CAF, teniendo en cuenta a la vez la compte de la possibilité de l'absence de учтена потенциальная недоступность posible indisponibilidad de un nivel soins de niveau approprié, en fonction de соответствующей медицинской adecuado de atención médica reque- la situation opérationnelle. L'article qui помощи в связи с оперативной обста- rida, debido a la situación operativa. El suit explique l'historique et la dimension новкой. В данной статье объясняется siguiente artículo explica la historia y el de cette matrice. история и формат этой матрицы. formato de dicha matriz.

40 MCIF 3/2015 From the CAF perspective, a stratified risk Level 1 Level 2 Level 3 matrix was subsequently formulated by the med tmt within med tmt within med tmt within Directorate of Medical Policy/Medical Stan- 72 hrs 24 hrs 1 hr dards, which balanced an acceptable level of < 10 % /10 years risk to the health and safety of CAF personnel, whilst taking into consideration the potential 10 – 20 % / 10 years unavailability of an appropriate level of med- 20 – 50 % / 10 years ical care required, due to operational situa- > 50 % / 10 years tion. In addition, it considers the potential effect of a medical event on an operational Tab. 1: Likelihood of Recurrence vs Severity of Outcome mission. However the acceptance of such risk, to include the probability of occurrences member, which could lead to serious out- Conclusion of medical conditions and consequences come or serious permanent disability, if D Med Pol/Med Stds utilizes the above risk thereof, is a Chain of Command decision. In medical support is not immediate. stratification matrix for several medical condi- this respect, the CAF Armed Force Council, a ii. Adverse medical consequences are likely to tions, some of which include seizure, traumatic General Officer forum, reviewed the original cause severe decrement in performance, as brain injury, cardiovascular events (specifically proposal and endorsed this approach. the member will be totally incapacitated personnel who have experienced a myocardial The finalized risk matrix approved (Table 1) and incapable of defending self; this will infarction), cerebrovascular accident, renal cal- (5), is now routinely utilized by D Med bring serious outcomes to the mission. culi and previous history of thromboembolic Pol/Med Stds, for review of appropriate med- events. For such conditions, medical employ- ical cases, for which risk stratification can be The risk stratification matrix is colour coded, ment limitations which are assigned will applied. Its purpose is to translate medical in a Red/Yellow/Green “stop-light” format, for include the probability of risk and level of med- employment limitations of CAF personnel with which a GREEN designation indicates a mem- ical care required and degree of incapacitation. significant medical conditions into a stratified ber has low medical risk within a military envi- This information is then evaluated by the Direc- risk. Each determination is an individualized ronment, for which a CAF member can con- torate of Military Career Administration, in assessment utilizing up to date scientific evi- tribute greatly with the assigned medical order to determine if a member can be retained dence to predict the probable future recur- employment limitations. For a YELLOW desig- or should be released from the CAF. By utilizing rence of a medical condition, level of medical nation, this indicates a CAF member would this approach, medical employment limitations care required and associated operational con- have a moderate medical risk within a military assigned provide a degree of flexibility for the sequences. The likelihood of recurrence is environment; however could contribute Chain of Command to make appropriate and divided into four levels of risk, which are acceptably with assigned medical employ- informed decisions, utilizing an individualized assigned over a 10 year time-frame, which are ment limitations. For a RED designation, this risk assessment for CAF members. This as follows: < 10 %/10 years, 10-20 %/10 indicates a CAF member would have a high approach is both scientific and defendable; it years, 20-50%/10 years and > 50%/10 years. medical risk within a military environment. In also results in optimizing retention of trained The severity of outcome is divided into three such cases, caution should be taken when experienced personnel, who would previously levels: considering unrestricted retention in these have been released from service, which is both Level 1 specific medical cases. advantageous to the member and the CAF. n i. Adverse medical consequences are likely to References: [email protected] cause physical or mental discomfort which would benefit from medical attention as soon as possible, but will rarely lead to AUTHOR long-term consequences. ii. Adverse medical consequences are likely to Commander C.H.T. Cross cause some decrement in performance and 1987 Graduated as a physician from the University of Liverpool Medical a CAF member would benefit from being School, UK. Completed the Diploma Royal College of Obstetricians and removed from duty; however the member Gynecologists and qualified as a Member of the Royal College of Gene- would be able to remain on duty and per- ral Practitioners. form the mission. 1992 Emigrated to Canada and practised as a General Practitioner. 2000 Joined the Cana- dian Armed Forces and was initially posted to CFB Esquimalt, as General Duty Medical Offi- Level 2 cer, trained as a Flight Surgeon and advanced Diving Medical Officer. 2004 Selected for Post- i. Adverse medical are likely to be in the form Graduate training in Undersea and Hyperbaric Medicine at USAF Undersea and Hyperbaric of an acute medical crisis. While immediate Medicine Centre, Brooks AFB, San Antonio, Texas, including a Master Degree Program in medical attention may not be crucial, lack Public Health. 2006 Posted to CFEME, DRDC Toronto as Consultant in Diving and Hyperbaric of timely medical attention could lead to Medicine and Head of Medical Group. 2008 Posted again to CFB Esquimalt. Deployed on OP some long-term consequences. PODIUM, for the 2010 Winter Olympics as Officer in Charge of the Vancouver Health Services ii. Adverse medical consequences are likely to Detachment. On return to CF Health Services Centre (Pacific), West-Coast Consultant in Diving cause moderate decrement in performance; and Submarine Medicine. 2013 Posted to the CF Health Services Group HQ, Ottawa, as however, will have difficulty fully safeguard- Senior Staff Officer at the Directorate of Medical Policy, Medical Standards and Policy. ing self and could be unfavourable to the 2015 Posted back to the west coast, as Pacific Regional Surgeon. mission. Address of the author: Level 3 PO Box 17000, Stn Forces i. Adverse medical consequences are likely to Victoria BC V9A 7N2, Canada cause serious medical outcome to a CAF

MCIF 3/2015 41 SUBPERIOSTEAL PREPARATION

M. STOETZER (GERMANY) Effects of a New Piezoelectric Device on Local Microcirculation and the Periosteum-Bone Interface after Subperiosteal Preparation

Subperiosteal preparation using a periosteal elevator leads to disturbances of local periosteal microcirculation. Soft-tissue damage can be considerably reduced using piezoelectric technology. In the study presented here, a novel device for the preparation of the periosteum was compared with a conventional periosteal elevator in an animal model.

Introduction Subperiosteal preparation using a periosteal elevator leads to disturbances of local periosteal microcirculation. Soft-tissue damage can be considerably reduced using piezoelectric technology. For this reason, we investigated the effects of a novel piezoelectric device on local periosteal microcirculation and compared this approach with the conventional preparation of the periosteum using a periosteal elevator. Material and methods. In the first part of the study, twenty Lewis rats were randomly assigned to one of two groups. Subperiosteal preparation was performed using either a piezoelectric device or a conventional periosteal elevator. Intravital microscopy was performed immediately after the procedure as well as three and eight days postoperatively. In the second part of the study, a further 50 Lewis rats underwent subperiosteal preparation with a piezoelectric Intravital fluorescence microscopy setup device or a conventional elevator. Specimens were obtained from these animals chemical and histological assessments con- phologically, the periosteum can be divided and examined immunohistochemically and firmed the superiority of the piezoelectric into three zones, each of which contains histologically at the aforementioned time device. highly specific cells. The inner zone is the points. Statistical analysis of microcirculatory Discussion. The use of a piezoelectric device osteogenic layer that contains cells similar to parameters was performed offline using for subperiosteal preparation is associated those of the endosteum. Among these cells analysis of variance (ANOVA) (p < 0.05). with better periosteal microcirculation than are mesenchymal stem cells, osteoprogenitor Results. At all time points investigated, intrav- the use of a conventional periosteal elevator. cells, active and resting osteoblasts, and/or ital microscopy demonstrated significantly As a result, piezoelectric devices can be active and resting osteoclasts. The middle higher levels of periosteal perfusion in the expected to have a positive effect on bone zone is a translucent layer that is charac- group of rats that underwent piezosurgery metabolism. terised by a large number of capillaries. The than in the group of rats that underwent treat- The periosteum is a membrane that consists outer zone is a typical fibrous layer that con- ment with a periosteal elevator. Immunohisto- of connective tissue and covers bone. Mor- tains collagen fibres. [1]

用骨膜剥离器进行骨膜下制备导致局部骨 La préparation sous périostale par l'utilisa- Поднадкостничная подготовка с La preparación subperióstica utilizando 膜微循环紊乱。使用压电技术可大大降低 tion d'une rugine (élévateur de périoste), использованием распатора приводит к un elevador perióstico conlleva pertur- 软组织损伤。本文提出了一种用于骨膜制 conduit à des perturbations de la microcir- нарушениям местной периостальной baciones de la microcirculación periós- 备的新装置，在动物模型中与常规骨膜剥 culation dans le périoste. Les dégâts sur микроциркуляции. Повреждения мягких tica local. El daño de los tejidos blan- 离器进行了对比。 ce tissu fragile peuvent être considérable- тканей могут быть значительно умень- dos puede reducirse considerablemente ment réduits par l'utilisation de la techno- шены с помощью пьезоэлектрической utilizando tecnología piezoeléctrica. En logie piézoélectrique. Dans l'étude présen- технологии. В представленном здесь el estudio que aquí presentamos, se tée ici, un nouvel appareil de préparation исследовании проводится сравнитель- comparó un dispositivo nuevo para la du périoste a été comparé à l'utilisation ный анализ нового устройства для при- preparación del periosteo con un eleva- d'une rugine conventionnelle sur un готовления надкостницы и обычного dor perióstico convencional en un modèle animal. распатора в животной модели. modelo animal.

42 MCIF 3/2015 The specific structure of the periosteum is by contrast, local periosteal microcirculation tain injuries to the facial skeleton and to the seen not only in children but also in adults is compromised, the regenerative potential of extremities during attacks and similar inci- and allows bones to remodel themselves over the periosteum will be reduced. Good dents. The periosteum plays a key role in the time, for example during bone fracture heal- periosteal microcirculation is of paramount healing of these injuries and its function must ing. [2–4] Periosteal cells play a major role in importance for bone modelling and remodel- be preserved as far as possible since an the supply of blood to the bone. The impor- ling. [12] In the literature, there is only a extensive loss of soft tissue and the separa- tance of intact periosteal tissue is underlined paucity of chronic studies on periosteal perfu- tion of periosteal tissue lead to compromised by the substantial contribution of periosteal sion during and after subperiosteal prepara- vascularity and are thus associated with poor blood cells to the supply of blood to cortical tion. bone healing. [26] bone (70–80% of arterial supply and Whereas (piezoelectric) ultrasonic instru- 90–100% of venous return) when compared ments have been available since 1988, Material and Methods to intraosseous blood vessels. [5] The perios- devices utilizing the piezoelectric effect have This study is based on animal experiments teum is closely attached to bone by collagen been used for medical purposes only since involving Lewis rats. Microcirculatory parame- fibres in the bone matrix and by hemidesmo- 1998. Applications of piezoelectric devices ters were assessed and histological sections somes. [6] Surgical procedures, especially include hard-tissue surgery, periodontal sur- were examined. those directly involving bone, often have gery, the removal of impacted teeth, apical adverse effects on the osteogenic potential of surgery [18, 19], and bone expansion [20, Experimental Animals the periosteum since they are associated with 21]. All procedures were approved by the respon- the detachment of periosteal tissue from the The piezoelectric effect is based on physical sible authority (Ref. 12/0861) and were per- bone. Periosteal damage can either be interactions in crystalline materials. The formed in accordance with the German Animal caused by the deliberate separation of the application of an electric field creates Protection Act and the Guide for the Care and periosteum from the bone during surgery or it nanoscale deformations in a crystal. This Use of Laboratory Animals [27]. The study can be the result of a disease or trauma. dynamic effect can be used to transform lon- involved 70 adult male Lewis rats with a body The preparation of the periosteum is a routine gitudinal or transverse movements of a ferro- weight between 300 g and 330 g (Harlan- procedure in trauma surgery, reconstructive electric material into a surgical cutting action. Winkelmann, Borchen, Germany). The rats surgery and especially dentoalveolar surgery. Piezoelectric devices are operated at different were housed singly in cages at a room tem- [7–10] It is commonly performed with a frequencies depending on the density of the perature of 22–24°C and a relative humidity periosteal elevator that is used for manually tissue to be cut. of 60–65% with a 12-hour day/night cycle. lifting and separating periosteal tissue from The tip of the ultrasonic device vibrates within They received water and dry food (Altromin, the bone. This procedure causes damage to a range of 20–200 μm at a frequency of Lage, Germany) at libitum during the entire the morphological structure of the periosteum 20,000 Hz. Piezoelectric devices are perma- investigation. and especially to the cells of the osteogenic nently cooled with sterile physiological saline layer. The result is a complete or partial loss during use so that heat-induced trauma can Study Design and of periosteal function. [11, 12] It is currently be ruled out [22, 23] and the risk of bacterial Experimental Groups impossible for surgeons to prepare the contamination is minimised. Microcirculatory parameters were assessed periosteum between the osteogenic layer and The essential difference between piezoelec- on day 0 immediately after subperiosteal the underlying bone in such a way that the tric devices and conventional preparation preparation with the different instruments periosteum remains intact. The use of a instruments is that piezoelectric devices oper- and on days 3 and 8 after the procedure. The periosteal elevator leads to the disruption of ate in a tissue-specific manner. Every tissue experiments were performed on the basis of a tissue at the periosteum-bone interface. The has a specific frequency range at which it can model established by Stuehmer et al. [28]. destruction of the connection between bone be cut. A piezoelectric device can therefore The rats (n=20) were divided into two experi- and periosteum damages the regenerative cut a specific type of tissue without causing mental groups. cells of the periosteum and reduces their damage to adjacent tissues. Damage to the Group 1 n=10, subperiosteal preparation osteogenic potential. [13–16] Successful soft tissues (e.g. nerves) that surround bone, with a periosteal elevator, osteoinduction and osteoconduction, how- for example, is caused only at frequencies intravital microscopy ever, require the preservation of cell vitality in above 50 kHz. [24, 25] In addition, piezoelec- Group 2 n=10, subperiosteal preparation the periosteum. [11] tric devices have the advantage that they with a piezoelectric device, Periosteal cells provide nutrition to the under- cause minimal bleeding when they are used intravital microscopy lying bone by free diffusion. Adequate func- to cut bone. The extent to which piezoelectric tioning of the periosteum is of far greater devices adversely affect periosteal microcir- Immuno-histochemical and histological sec- importance to patients who have underlying culation has not yet been investigated. While tions were examined after the animals had diseases such as diabetes mellitus or there are a few studies that address the been killed. This part of the study involved 50 undergo tumour treatment and receive behaviour of bone when it is being cut by rats that were divided into five experimental chemotherapeutic agents than it is to healthy piezoelectric devices, there are no studies groups. people since the periosteum plays an impor- that examine local microcirculation within the Group 1 n=10, control group tant role in promoting rapid bone healing. If periosteum during and after the cutting opera- Group 2 n=10, subperiosteal preparation with these patients undergo surgery involving tion. We conducted this study in order to a piezoelectric device, im - bone, particular care must be taken to cause investigate the effects of piezoelectric surgery muno-histochemistry and his- no damage or as little damage as possible to on local periosteal microcirculation and com- tology after three days of heal- the periosteum with a view to ensuring subse- pared the use of a piezoelectric device and a ing quent bone healing without dehiscences or conventional periosteal elevator for the Group 3 n=10, subperiosteal preparation with necrosis. [17] If the bone is damaged without preparation of the periosteum. This issue is of a periosteal elevator, immuno- compromising local periosteal microcircula- particular importance in the military setting histochemistry and histology tion, good bone healing can be expected. If, since it is not uncommon for soldiers to sus- after three days of healing

MCIF 3/2015 43 Group 4 n=10, subperiosteal preparation with Schwerte, Germany) and transferred to a DVD Solms, Germany). H&E staining was used for a a piezoelectric device, im mu - system (LQ-MS 800, Panasonic, Hamburg, descriptive analysis of the periosteum-bone nohistochemistry and histol- Germany) for off-line evaluation. interface. The specimens were stained for col- ogy after eight days of healing lagen type I and type IV and osteocalcin for Group 5 n=10, subperiosteal preparation with Histology and immunohistochemical analysis. The piezo- a periosteal elevator, immuno- Immunohisto-Chemistry electric device groups were then compared histochemistry and histology Formalin-fixed and paraffin-embedded speci- with the periosteal elevator groups. after eight days of healing. mens were cut into 5-μm-thick sections, stained with haematoxylin and eosin (H&E) Statistical Analysis Procedures and examined by microscopy (DM4000B Leica Normal distribution and homogeneity of vari- The animals were anaesthetised using an Mikrosysteme, Wetzlar, Germany). Formalin- ance were assessed. Results are expressed as intraperitoneal injection of ketamine fixed and paraffin-embedded specimens were means and standard errors of measurement (Ketavet®, 75 mg per kg bodyweight, Parke- also cut into 5-μm-thick sections for immuno- (SEM). Differences between groups were eval- Davis, Germany) and xylazine (Rompun®, 25 histochemical analysis. The following anti- uated with a one-way analysis of variance mg per kg bodyweight, Bayer HealthCare, Ger- bodies were used: rabbit anti-collagen type I (ANOVA) on ranks. Differences within groups many). A surgical blade was used to make an (1:800, BIOLOGO, Kronshagen, Germany), were also analysed by ANOVA. Student-New- incision through the skin and periosteum in rabbit anti-collagen type IV (1:400, Acris Anti- man-Keuls or Duncan post-hoc tests were the occipital region in order to expose the cal- bodies GmbH, Hiddenhausen, Germany), rab- used to isolate specific differences. A p-value varia. Depending on the group, either a bit anti-collagen type VI (1:200, Acris Antibod- < 0.05 was considered significant. Data was periosteal elevator or a piezoelectric device ies GmbH, Hiddenhausen, Germany), mouse collected and analysed using Microsoft Office was used for the preparation procedure. The anti-osteocalcin (1:200, QED Bioscience Inc., Excel 2007 and IBM SPSS (Statistics 21, IBM skin was then repositioned and secured in San Diego, USA), and mouse anti-SPARC Deutschland GmbH, Germany). place with sutures (Ethicon Vicryl® sutures (1:200, Santa Cruz Biotechnology, Santa 4–0, Johnson & Johnson, Germany). The pro- Cruz, USA). A biotin-conjugated goat anti-rab- Results cedure took approximately ten minutes. bit antibody (1:600, Dianova, Hamburg, Ger- Intravital fluorescence microscopy Intravital microscopy was performed subse- many) or a biotin-conjugated goat anti-mouse Periosteal microcirculation was imaged in quently. Periosteal vascularisation was antibody (1:200, Dianova, Hamburg, Ger- detail using intravital fluorescence analysed by intravital microscopy on the fol- many) was used as a secondary antibody. microscopy. The group of rats whose perios- lowing days at the time points indicated Incubation with streptavidin-horseradish per- teum had been prepared with a piezoelectric above. Every microscopic examination took oxidase (Dianova, Hamburg, Germany) was device was compared with the group of rats approximately thirty minutes. After either followed by colour development with whose periosteum had been prepared with a three or eight days of healing, the animals aminoethylcarbazole (AEC) substrate (Axxora periosteal elevator. were killed using an overdose of anaesthet- Deutschland GmbH, Loerrach, Germany) at ics. Specimens were obtained and prepared room temperature. Colour development was Functional capillary density for histological and immuno-histochemical stopped under microscopic control by wash- The periosteal elevator groups showed an analyses. ing with water. The sections were counter- increase in functional capillary density from stained with haematoxylin (Merck, Darmstadt, day 0 to day 8. This density, however, was Intravital Fluorescence Germany) and examined by light microscopy always lower in the periosteal elevator group Microscopy of the Periosteum (DM4000B Leica Mikrosysteme, Wetzlar, Ger- than in the piezoelectric device group. In the Under anaesthesia with intraperitoneal keta- many). piezoelectric device group, mean functional mine (Ketavet®, 75 mg per kg bodyweight) capillary density decreased by 11.73 cm/ and xylazine (25 mg per kg bodyweight), Analysis of Intravital cm2, from 80.69 cm/cm2 on day 0 to 68.96 intravital fluorescence microscopy was per- Fluorescence Microscopy cm/cm2 on day 3. It then increased to 127.95 formed immediately after the preparation of Computer-assisted quantitative image analy- cm/cm2 on day 8 and was higher than in the the periosteum and on days 3 and 8 after the sis was performed off-line using CapImage procedure. Fluorescein-isothiocyanate- image analysis software (Zeintl, Heidelberg, labelled dextran (FITC-dextran, molecular Germany). Functional capillary density, micro weight: 150,000 Da, Sigma, Taufkirchen, Ger- vessel diameters and volumetric blood flow many, 5% in 0.9% NaCl solution, 0.1 ml) was were determined in the venules. Functional injected into the tail vein of each animal for vessel density was assessed on the basis of contrast enhancement of blood plasma. This the length of perfused micro vessels per technique permitted the imaging of microcir- observation area. Diameters (d) were meas- culation. All examinations were recorded on- ured perpendicular to the vessel path and are line using a highly sensitive video camera and expressed in mm. Volumetric blood flow was quantitatively analysed (off-line) with com- calculated using the formula: π x (d/2)2 x v/K, puter assistance at a later time in order to where K represents the Baker-Wayland factor minimise examination times. Reflected light to correct for the parabolic velocity profile in fluorescence microscopy was performed micro vessels with a diameter > 20 μm. using a Zeiss Axiotech microscope (Zeiss, Oberkochen, Germany) at 20x magnification. Histological Analysis A blue filter block (450–490 nm) permitted Histological analysis was performed using Functional capillary densities on days 0, 3 and the visualisation of blood plasma. Micro- analySIS software (Soft Imaging System 8. For a better view, the y-axis uses a scopic images were recorded using a highly GmbH, Muenster, Germany) and a Leica logarithmic scale. Outliers are represented as sensitive video camera (FK 6990 IQ-S, Pieper, DM4000B light microscope (Leica Camera AG, circles and extreme values as asterisks.

44 MCIF 3/2015 Days after Periosteal elevator group Piezoelectric device group surgery [cm/cm2] (mean/SD) [cm/cm2] (mean/SD) 0 22.73 ± 13.98 80.69 ± 17.66 3 31.00 ± 18.67 68.96 ± 20.31 8 120.15 ± 99.31 127.96 ± 36.56

Means and standard deviations (SD) for functional capillary density

periosteal elevator group at all time points. electric device group on days 0 and 3. Densi- These results show that a major increase in ties were more similar after eight days of heal- mean functional capillary density occurred no ing. At this time point, the difference between earlier than after eight days of healing. From the two groups in mean capillary density was day 3 to day 8, mean functional capillary den- only 7.8 cm/cm2. Means and standard devia- sity increased by 387% in the periosteal ele- tions are given in the next table. vator group and by 185% in the piezoelectric Red blood cell velocities on days 0, 3 and 8. device group. The difference between the rats Red blood cell velocity For a better view, the y-axis uses a logarithmic whose periosteum had been prepared with a On day 0, red blood cell velocity was 0.31 scale. Outliers are represented as circles and extreme values as asterisks. periosteal elevator and the rats whose perios- mm/s (± 0.12) in the periosteal elevator group teum had been prepared with a piezoelectric and 0.69 mm/s (± 0.43) in the piezoelectric ferences between the two groups were signifi- device was significant postoperatively as well device group. During eight days of healing, cant (p > 0.05). At all time points, mean red as after three and eight days of healing (p > both groups showed an increase in mean red blood cell velocities were significantly higher 0.05). During the entire observation period, blood cell velocities. The highest increase in the piezoelectric device group than in the mean functional capillary density was higher was noted for both groups on day 8. At this periosteal elevator group. The highest velocity in the piezoelectric device group than in the time point, mean red blood cell velocity was (2.93 mm/s) was measured on day 8 for an periosteal elevator group. Capillary density in 1.76 times higher in the piezoelectric device animal in the piezoelectric device group and the periosteal elevator groups was less than group than in the periosteal elevator group. was 2.25 times higher than the mean red half as high as that observed for the piezo- During the entire observation period, the dif- blood cell velocity. Red blood cell velocities

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ATMOS MedizinTechnik GmbH & Co. KG Ludwig-Kegel-Str. 16 79853 Lenzkirch/Germany Phone: +49 7653 689-0 mail: [email protected] www.atmosmed.com When the periosteum was prepared with a Days after Periosteal elevator group Piezoelectric device group conventional periosteal elevator, the bone

surgery [mm/s] (mean/SD) [mm/s] (mean/SD) surface showed clear evidence of mechanical 0 0.31 ± 0.12 0.69 ± 0.43 damage resulting from the use of the instru- ment. The inner zone of the periosteum was

3 0.42 ± 0.25 0.72 ± 0.31 torn from the bone and there was no clear 8 0.75 ± 0.34 1.30 ± 0.78 demarcation between the different layers. This type of damage did not occur when the Means and standard deviations (SD) for red blood cell velocity piezoelectric device was used.

were almost constant in the piezoelectric Light microscopy Collagen type I device group and increased only moderately Light microscopical examinations of haema- In both groups, collagen type I levels were in the periosteal elevator group during the toxylin-eosin-stained specimens showed vari- approximately identical on day 3 but different observation period. Means and standard devi- ous degrees of changes in bone morphology on day 8. At the latter time point, collagen ations are shown in the next table. and histo-morphology. type I levels were significantly higher in the There were considerable qualitative differ- piezoelectric device group than in the Vessel diameter ences at the periosteum-bone interface periosteal elevator group. The periosteal elevator group showed a signif- between the periosteal elevator group and the icant increase in mean vessel diameter from piezoelectric device group. When the perios- day 0 to day 3 (p > 0.05). After eight days of teum was prepared using the novel piezoelec- healing, the mean vessel diameter was tric device, the bone surface was smooth and smaller than on day 3 but not as small as that showed no evidence of mechanical damage. measured postoperatively. In the piezoelec- The different histological layers of the perios- tric device group, the mean diameter of per- teum were clearly demarcated. The outer fused vessels decreased from day 0 to day 3 fibrous layer and the inner cambium layer and then increased until day 8. After eight were clearly visible. Fat vacuoles and collage- days of healing, the mean vessel diameter nous connective tissue were identified as well. was similar to that measured on day 0. The difference was only 0.33 μm. A comparison of the two groups showed that the mean diameters in the periosteal elevator group were significantly smaller than those in the piezoelectric group during the entire observation period (p > 0.05). Means and standard deviations are Collagen type I levels at different time points given in the next table. after subperiosteal preparation using a piezoelectric device or a periosteal elevator. Outliers are represented as circles and extreme Histological image after preparation with a values as asterisks. piezoelectric device demonstrating the periosteum (star), bone (circle) and the border Collagen type IV between the periosteum and bone (arrow) After the surgical intervention, collagen type IV levels in the piezoelectric device group were similar to those obtained for the

Vessel diameters on days 0, 3 and 8. For a image after preparation with a periosteal better view, the y-axis uses a logarithmic scale. elevator demonstrating the periosteum (star), Outliers are represented as circles and extreme bone (circle) and the border between the values as asterisks. periosteum and bone (arrow)

Days after Periosteal elevator group Piezoelectric device group surgery [ m] (mean/SD) [ m] (mean/SD) 0 8.94 ± 7.40 17.72 ± 5.36 Collagen type IV levels at different time points 3 14.57 ± 6.37 16.78 ± 6.71 after subperiosteal preparation using a 8 13.86 ± 2.40 17.39 ± 5.25 piezoelectric device or a periosteal elevator. Outliers are represented as circles and extreme Means and standard deviations (SD) for vessel diameter values as asterisks.

46 MCIF 3/2015 periosteal elevator group and significantly Our results show that the use of the piezo- (six times) higher than those of the control electric device for the preparation of the AUTHOR group. After eight days of healing, collagen periosteum was associated with a consider- type IV levels had almost returned to those of ably higher post-procedural periosteal blood LtC DC the control group. At this time point, collagen flow than the conventional method with a Dr Marcus type IV levels were still (five times) higher in periosteal elevator. Stoetzer the periosteal elevator group. One possible explanation is that the use of a 2001 Entry German Armed Forces as Osteocalcin piezoelectric device leads to the formation of Medical Officer Cadet During the observation period of eight days, fewer micro thrombi during subperiosteal 2001–2007 Study of dental medicine at there was a significantly more pronounced preparation than a periosteal elevator. Func- Christian Albrechts University, Kiel, Ger- increase in osteocalcin levels in the piezo- tional capillary density was significantly many electric device group than in the periosteal higher after preparation with a piezoelectric 2007–2009 Unit Dental Officer in elevator group. device. As a result, a considerably higher Schwanewede number of perfused vessels were available for 2010–2011 Head of Branch 4 Dentistry, periosteal supply. In addition, the piezoelec- Department of Healthcare, GAF Medical tric device was associated with a significantly Command I higher microvascular blood flow than the 2010 Doctorate in dental medicine periosteal elevator. Histological assessments 2011–2014 Post-graduate training as of the effects of trauma on tissue and the dental specialist for oral surgery at immuno-histochemical staining of tissue Hannover University Medical School. specimens are common methods for examin- Since 2014 Oral surgeon at medical ing tissue. [33] In the study presented here, center Seedorf the analysis of histological sections shows that a piezoelectric device is superior to a Deployments: OEF 2008; ATALANTA 08-09; ISAF 2009; RSM 2015 conventional periosteal elevator in preparing the periosteum. Address of the author: Dr. Marcus Stoetzer, DDS, LTC (DC) Vessel density in the periosteum plays an Oral surgeon Osteocalcin levels at different time points after important role in the supply of blood to bone. Fallschirmjäger Kaserne subperiosteal preparation using a piezoelectric [5] Every surgical procedure that leads to sub- Sanitätsversorgungszentrum Seedorf device or a periosteal elevator periosteal exposure results in a decrease in Twistenberg 120 periosteal perfusion. [3] Several studies 27404 Seedorf, Germany reported that piezosurgery is an atraumatic E-mail: [email protected] Discussion process that causes only minimal tissue dam- In the study presented here, a novel device for age. [34] In the future, this technique can play the preparation of the periosteum was com- a key role in the management of compro- pared with a conventional periosteal elevator mised patients since the vascular layer of the in an animal model. The technique that was periosteum is largely preserved. This is one of used in this study is an established method. the principles of biological osteosynthesis, Correction It has been used by Menger et al. in the past which is used in the fields of orthopaedics twenty years and allows us to compare the and trauma surgery. Periosteal preparation “Bladder Injuries various groups. with a piezoelectric device can be an option in Military Conflicts” especially in the treatment of fractures that Microvascular perfusion of different types of soldiers sustain during attacks and similar The Curriculum Vitae of the author of the tissues can be investigated in vivo by a vari- incidents and that are associated with above article, published in MCIF issue ety of methods such as laser Doppler flowme- severely compromised tissue. The use of 2/2015, contained translation errors. Here the correct wording: try and polarographic oximetry. [3, 27, 28] The piezoelectric devices for periosteal prepara- main disadvantage of these methods is that tion may considerably improve the outcome Curriculum Vitae tissue perfusion can be imaged only indirectly of patients with injury patterns similar to Name: Daniela Dinger, Major MC, MD and that no information about the perfusion those seen in military operational settings. Studies: 2000–2007 study of medicine at of individual micro vessels can be obtained. The results reported here show that the use of Hamburg University, Germany and Palermo By contrast, intravital microscopy offers the a piezoelectric device for the preparation of University, Italy Occupation: 2007- 2009 resident in the possibility of studying the perfusion of indi- the periosteum has considerable advantages. clinic and polyclinic for urology, University vidual micro vessels even over a prolonged Further studies are required to investigate Medical Center Schleswig-Holstein, Campus period of time. [27, 29] This method has been possible effects in patients who have comor- Lübeck shown to be suitable for investigating bidities and, for example, are treated with bis- 2010–2011 surgical resident in the depart- periosteal perfusion in other studies. [30, 31] phosphonates, chemotherapeutic agents or ment for visceral medicine in the Asklepios We determined functional capillary density, other medications and in soldiers who sus- Clinic Wandsbek, Hamburg blood flow within micro vessels and the diam- tained blast injuries that are challenged by Since 11/2011 resident in the department for urology in the Hamburg Military Hospital, eters of micro vessels in the periosteum in poor soft-tissue quality and may include ther- first as Captain (MD), since 11/2013 as order to investigate whether a piezoelectric mal injuries. Such studies are underway but Major (MD) and specialist for urology device causes less irritation to micro vessels results are not yet available. than a conventional periosteal elevator. References: [email protected]

MCIF 3/2015 47 DISASTER MEDICINE SERVICE OF THE RUSSIAN FEDERATION

S. GONCHAROV, O. GARMASH (RUSSIAN FEDERATION) Quality Increase of Emergency Health Care to the Injured – the Top Priority for Disaster Medicine

The Fundamental Healthcare Principles and the National Program of Health Development in the Russian Federation define that the priority task of the Russian public health services is to increase the quality of medical care [1]. Medical care management and delivery in emergencies, including medical evacuation of the injured, are implemented by the All-Russian Service for Disaster Medicine.

The main federal regulations and standards - The main tasks of Disaster Medicine Service Federal law of the Russian Federation of in emergency medical care arrangement and November 21, 2011 #323-F3 “On Fundamen- delivery in emergencies are the following: tal Healthcare Principles in the Russian Feder- prompt response; mobilization of public ation” and National Program of the Russian health man-power and resources; movement Federation “Health Development”, approved of the Services’ units to emergency zones; by the Decree of the Government of the Russ- arrangement and timely delivery of medical ian Federation of 15.04.2014 #294- define care to the injured; medical evacuation of the that priority task of the Russian public health injured. is to increase quality of medical care [1]. According with the Article 32 of the Federal Article 41 of the Federal law of the Russian law of the Russian Federation of November Federation of November 21, 2011 #323-F3 21, 2011 #323-F3 “On Fundamental Health- “On Fundamental Healthcare Principles in the care Principles in the Russian Federation” care in urgent form“ was included in the new Russian Federation” says: “Medical care man- emergency medical care is given in sudden version of the National Program “Public agement and delivery in emergencies, includ- acute diseases and states, acute exacerba- Health Development”. In disaster medicine, ing medical evacuation of the injured, are tion of a chronic disease, challenging life. timeliness and accessibility of emergency implemented by All-Russian Service for Disas- medical care are ambiguous notions. ter Medicine”. Analysis shows that needs in emergency med- In emergencies, such as earthquakes and Annually in the Russian Federation, emergen- ical care in everyday life is up to 15% and in explosions the injured are in debris of ruined cies occur in 75-80 regions and it is necessary emergency response it is more than 60% of buildings without any access. In these situa- to give emergency medical care to more than all medical care delivered to population. tions, the role of emergency rescue units is of 30 thousand injured people. Annual relative Thus, timeliness (accessibility) and quality of vital importance [2]. stable number of the injured and died speaks emergency health care are of vital signifi- In everyday life mainly the injured in road about necessity of constant increase of the cance. accidents and residents of far and difficult of public health preparedness for emergency Considering social significance of emergency access regions including households need response [2]. medical care, the necessity to provide conti- emergency health care. Preparedness to implement tasks in emergen- nuity of all types of emergency medical care At emergency site ambulance teams play the cies is carried out by the permanent improve- delivered to the injured, a Subprogram main role in giving emergency health care to ment of medical institutions every day activ- “Development of emergency medical care, the injured and their evacuation to the med- ity. Operative-dispatching services play a including the specialized one, primary health ical institutions. Thus, in 2014 more than considerable role in it. care in urgent form and specialized medical 5400 mobile medical teams worked at emer-

俄罗斯联邦国家基本医疗原则和健康发展 Les Principes Fondamentaux de Santé et В фундаментальных принципах охраны Los Principios Sanitarios Fundamenta- 国家计划（The Fundamental Healthcare le Programme National de Développement здоровья и Национальной программе les y el Programa Nacional de Desarro- Principles and the National Program of de la Santé dans la Fédération de Russie развития здравоохранения в Россий- llo de la Salud de la Federación de Health Development in the Russian Fed- précise que la nécessité prioritaire des ской Федерации определено, что прио- Rusia definen la tarea prioritaria de los eration）定义了俄罗斯公共卫生服务的优 services Russes de santé publique est ритетной задачей российского здраво- servicios sanitarios públicos rusos para 先任务是提高医疗服务的质量[1]。在紧急 d'améliorer la qualité des soins. C'est le охранения является повышение incrementar la calidad de la atención 情况下的医疗护理管理和实施（包括伤者 Service Panrusse de Médecine de Catas- качества медицинской помощи [1]. médica [1]. La gestión y la prestación 的医疗撤离）由全俄灾害医学服务机构（ trophe qui gère et active les soins d'ur- Управление медицинским обслужива- de asistencia médica en emergencias, All-Russian Service for Disaster Medicine gences, y compris l'évacuation sanitaire нием и оказанием медицинских услуг в incluida la evacuación médica de heri- ）实施。 des blessés. чрезвычайных ситуациях, в том числе dos, se implementan gracias al Servicio медицинской эвакуации раненых, осу- integral ruso de medicina ante desas- ществляются Всероссийской службой tres. медицины катастроф.

48 MCIF 3/2015 gency sites, among them 95% were ambulance teams. During work in emergency, the role of the first medical team, which arrives at the accident site, is of utmost importance. Head of the team is responsible for medical evacuation in emergency zone and primarily for medical triage and emergency medical care and, according with the requirements of Health Ministry of the Russian Federation, for urgent submitting a report to the dispatcher service of the Territorial Centre for Disaster Medicine. Variants of work of Disaster Medicine Ser- vice’s medical teams (mobile medical teams, field multipurpose hospitals, permanent ready specialized medical teams, etc.) are tested in practice of hundreds and thousands emergency responses, beginning from the military conflict in the North Caucasia. To provide emergency health care accessibility and quality for the residents, including those living in the sparsely populated areas and households it is planned to establish or improve existing subdivisions (emergency dispatcher departments)(working on the base sary financial conditions for air companies - nn arrangement of interhospital evacuation to of emergency consultative health care and aircraft operators and introduction of long- the specialized medical institutions; medical evacuation departments of Territorial term national contracts with air companies for nn delivery of medical mobile specialized con- Centres for Disaster Medicine) of the Inte- the term exceeding expiration date of sultative teams to other regions; grated Dispatcher Service of the Executive approved limits of budget commitments. nn transportation of transplantation organs Authority of the Russian constituent entity While developing air medical service it is and donated blood to the special medical (hereinafter referred to as the Region) in the advisable to use experience of the regions of institutions equipped with helicopter field of population health care. the Russian Federation efficiently introducing landing sites. Operational-dispatching department of Terri- mechanisms of public-private partnership [6, At the expense of “Helidrive” company, heli- torial Centres for Disaster Medicine works 7, 8]. copter landing sites were built for inter-dis- round-the-clock, it should be equipped with Cooperation of national health care authori- trict medical institutions of Leningrad region, modern communication facilities, including ties of Leningrad region and St. Petersburg light helicopters with medical equipment Internet, providing receiving and exchange of with the Limited Liability Company “Helidrive” were bought and round the clock dispatcher information with all executive bodies of the can serve as an example of such partnership, service was organized. Russian Federation’s regions, which partici- when the following tasks are solved: The first experience has already shown that pate in emergency response; ambulances, nn arrangement of medical air evacuation of development of air medical service on the medical and local institutions, villages and the injured in road accidents; basis of public-private partnership will reduce households. nn transportation of the patients to the aircraft operating and maintenance costs. n Operational-dispatcher department should megalopolis hospitals, equipped with the have the following functions: collection and helicopter landing sites; References: [email protected] analysis of health information; monitoring of severely injured patients in medical institutions; monitoring of arrangement and delivery of emergency health care, including emer- AUTHORS gency consultative medical care, to the residents of far and difficult of access regions. Prof Dr Sergei Goncharov, MD Ministry of Health of the Russian Federation Academician of the Russian Academy of Sciences works to provide accessibility of medical care Director, ARCDM “Zaschita”, Ministry of Health, Russia for the population and this work includes, Born: October 19, 1949, USSR among other things, development of emer- Address of the author: gency consultative medical care and medical All-Russian Centre for Disaster Medicine "Zaschita" evacuation (air medical service) [3,4,5]. Ministry of Health of the Russian Federation Analysis of the information presented by 5, Schukinskaya Street; Moscow 123182; Russian Federation regions of the Russian Federation showed Phone/ Fax: +74991905287; +74991905461 that development of air medical service E-mail: [email protected] demands sufficient number of modern air- First and corrsponding author crafts, equipped with special medical mod- ules; available helicopter landing sites and CO-AUTHOR runways; well-developed infrastructure for O. Garmash efficient operation and maintenance; neces-

MCIF 3/2015 49 AIR QUALITY MONITORING

J. D. LALONDE, M. BRADLEY (CANADA) 11 Years of Air Quality Monitoring in Afghanistan

Environmental factors can present serious risk factors to deployed military personnel. These factors may include hot humid climates, disease vectors as well as environmental hazards - both manmade and natural - that may be present in the background. This article describes the Canadian Armed Forces Deployable Health Hazard Assessment Team and its tasks.

Introduction analysis. Once the laboratory results are Identification of Compounds In addition to the risks associated with mod- received, they are screened to identify com- of Potential Concern ern operations in deployed settings, Canadian pounds of potential concern (CoPC) to CAF Each Afghanistan TAV generated thousands of Armed Forces (CAF) personnel must cope with members’ health. Subsequently, DFHP pre- individual air quality results. In order to sort environmental factors. The CAF’s Health Serv- pares a report that contains proposed mitiga- through these results and pick out those that ices Group has responded to these potential tion measures to reduce potential occupa- were most likely to cause either short-term or additional risks by creating the Directorate tional and environmental exposures. This long-term adverse health effects (also called Force Health Protection (DFHP). DFHP’s mis- report is sent to CJOC, the Command Team in compounds of potential concern or CoPC), sion is to protect and promote the health and theater, and the Directorate Health Services each result was compared to the most up to well-being of the CAF and its members, with Operations. date internationally recognized health bench- leadership, stewardship, and partnership in DHHAT was present throughout the CAF’s mis- marks, guidelines or standards. Exceeding support of the DND/CAF mission – anytime, sion in Afghanistan with 11 TAVs being suc- these typically conservative thresholds does anywhere. In particular, DFHP activates its cessfully completed over an 11-year period not necessarily imply that adverse health Deployable Health Hazard Assessment Team between 2003 and 2014. The TAVs took place effects would occur but rather raises the need (DHHAT) to assess potential occupational and in either Kabul or Kandahar depending on to conduct a toxicological assessment. environmental hazards in deployed settings where CAF personnel were living and working. The Afghanistan air quality results were when tasked by the Canadian Joint Opera- The focus of these Afghanistan TAVs varied screened using the current American Confer- tions Command (CJOC). depending on each deployment’s specific ence of Governmental Industrial Hygienists DHHAT is made up of Bioscience Officers, Pre- environmental and occupational concerns. (ACGIH) Threshold Limit Values (TLV) time- ventive Medicine Technicians, and is sup- They covered a wide spectrum of monitoring weighted average (TWA). The National Institute ported by DFHP’s Laboratory Manager, Occu- and sampling including air quality measure- for Occupational Safety and Health (NIOSH) pational and Environmental Physicians, ments, water potability assessments, spill Recommended Exposure Limit (REL)-TWA was Toxicologist, and Industrial Hygienist. DHHAT investigations, building material analyses and another health-based standard used to assess collaborates with the DFHP’s experts and noise surveys. contaminants in air. For airborne compounds deployed medical personnel to conduct pre- The emphasis of this article will be on the air with no existing ACGIH or NIOSH standards, deployment assessments of potential health quality in Afghanistan since air quality was public health-based ambient air criteria were hazards in the CAF areas of operation. Once the main health concern throughout this mis- employed, such as the United States Environ- potential hazards are determined, a sampling sion. Table 1 details when and where the mental Protection Agency (US EPA) national plan is developed, which DHHAT executes by DHHAT TAVs took place, the list of com- ambient air quality standards for particulate completing a technical assistance visit (TAV) pounds or group of compounds that were matter and the Ontario ambient air quality cri- to the deployed setting. On these TAVs, measured in air, and which one was identified teria for dioxins and furans (D/F). DHHAT collects environmental samples that as being a CoPC to CAF members deployed to The ACGIH TLV-TWA and the NIOSH REL-TWA will be shipped to an accredited laboratory for Afghanistan. are standards derived for occupational

环境因素可能使部署的军事人员存在严重 Les facteurs environnementaux peuvent Экологические факторы могут пред- Los factores medioambientales pueden 的危险因素。这些因素可能包括大环境中 être des facteurs de risque pour le person- ставлять серьезный риск для военно- presentar factores de riesgo graves en 出现的湿热气候、疾病载体以及环境危害 nel militaire en mission. Ces facteurs peu- служащих развернутых подразделе- el despliegue de personal militar. Estos （包括人为和自然环境危害）。本文介绍 vent inclure les climats chauds et ний. Эти факторы могут включать в factores pueden incluir climas cálidos y 了加拿大军队可部署健康危害评估小组（ humides, les vecteurs de maladies et les себя жаркий и влажный климат, пере- húmedos, vectores de enfermedades y Canadian Armed Forces Deployable dangers environnementaux - d'origines à носчики болезней, а также такие эколо- peligros ambientales, tanto causados Health Hazard Assessment Team）及其 la fois humaines ou naturelles – éventuel- гические опасности - как искусствен- por el hombre como naturales, que 任务。 lement présents dans le contexte. Cet ные, так и естественные - которые pueden estar presentes de fondo. Este article décrit l'Équipe Déployable des могут присутствовать в естественной artículo describe en qué consiste el Forces Armées Canadiennes d'Évaluation среде. В данной статье описывается Equipo desplegable de evaluación de des Risques de Santé, ainsi que ses mis- группа по оценке опасности для здо- peligros para la salud de las Fuerzas sions. ровья Вооруженных сил Канады и ее Armadas Canadienses y sus tareas. задачи.

50 MCIF 3/2015 Location Date Compounds monitored in air CoPC Total particulates Metal scan Respirable particulates VOC 2003 PM PAH Kabul 10 PM Jun Crystalline silica 1-3-butadiene 10 Asbestos fibres Formaldehyde Elemental carbon Acetaldehyde Total particulates Elemental carbon Respirable particulates Metal scan 2003 PM Kabul 10 PM10 VOC Oct PM2.5 PM2.5 PAH Crystalline silica 1-3-butadiene Total particulates VOC 2005 PM PAH Kandahar 10 PM Jul Crystalline silica 1-3-butadiene 10 Metal scan Total particulates PAH PM 1-3-butadiene 2006 10 Kabul Crystalline silica Sulphur oxides PM Feb 10 Metals scan Nitrogen oxides VOC Total particulates Crystalline silica 2007 Respirable particulates Metal scan Kandahar * Oct Asbestos fibers VOC

PM10 PAH Total particulates PM2.5 PM 2009 10 Kandahar Respirable particulates Crystalline silica PM Dec 2.5 Crystalline silica PM10 Asbestos fibres PM Elemental carbon PM 2010 10 10 Kandahar PM VOC PM ‘120 days of wind’ 2.5 2.5 Crystalline silica PAH Crystalline silica 2011 PM Crystalline silica PM Kandahar 10 10 Mar-Apr PM PM2.5 2.5 Total particulates Elemental carbon 2011 PM Metal scan PM Kandahar 10 10 Oct-Nov PM PM2.5 VOC 2.5 Crystalline silica Total particulates Carbon monoxide PM PM10 Ozone 10 2011 PM Metal scan PM Kabul 2.5 2.5 Nov-Dec Crystalline silica VOC Crystalline silica Sulfur dioxide PAH D/F Nitrogen dioxide D/F 2014 PM Crystalline silica PM Kabul 10 10 PM Jan-Feb PM2.5 2.5

Tab.1: Locations and dates of the Deployable Health Hazard Assessment Team (DHHAT) Afghanistan technical assistance visits (TAVs), compounds measured in air and compounds of potential concern (CoPC) identified.

Notes: PM = particulate matter PAH = polycyclic aromatic hydrocarbon

PM2.5= PM equal to or less than 2.5 μm in diameter VOC = volatile organic compounds PM10 = PM equal to or less than 10 μm in diameter D/F = dioxins and furans * PM10 results from this TAV were unreliable due to a sampling error

airborne exposures. They represent airborne a working lifetime. On balance, it is believed their respective health threshold on at least concentrations of substances to which nearly that these occupational health thresholds pro- one occasion and were therefore identified as all workers can be repeatedly exposed over vide a reasonable, though conservative, com- a CoPC; crystalline silica, D/F, and PM (Table their entire working lifetime without adverse parative benchmark for occupational airborne 1). Crystalline silica exceeded its health stan- health effects, based on an 8-hour workday exposures while on deployment. Airborne con- dard on three separate TAVs, two to Kandahar and a 40-hour work week. These occupational taminants that were measured at levels that (2009, 2010) and one to Kabul (2011). D/F standards are not completely suitable for CAF were below the TLV-TWA or REL-TWA would not measured above the health guideline in 2011 personnel in deployed settings because CAF be expected to produce long-term adverse from a TAV to Kabul. PM produced consis- personnel could be exposed to compounds in health effects in CAF members. tently high results on at least one occasion air for periods exceeding the standard 8-hour From all of the air quality sampling and moni- from all the TAVs completed in Afghanistan. work day and 40-hour workweek. However, the toring performed in the 11 years of TAVs in Potential health impacts of crystalline silica, duration of their deployment is much less than Afghanistan, only three analytes exceeded D/F, and PM will be discussed below.

MCIF 3/2015 51 Crystalline Silica Crystalline silica is a basic component of soil, sand, granite and has three main forms: cristo- balite, tridymite and α-quartz. The predominant species of crystalline silica in Afghanistan is α- quartz (Engelbrecht et al., 2008). Indeed, when detected, all crystalline silica results from the Afghanistan TAVs where observed to be of the α-quartz form. Crystalline silica, including α- quartz, is a mechanical irritant to lung tissue and has been listed by the ACGIH as an A2, suspected human carcinogen (ACGIH, 2015). There is evidence that some forms of pulmonary fibrosis are risk factors for human lung cancer and sufficient exposure to crystalline silica can cause some of these forms of pulmonary fibrosis (ACGIH, 2010). Crystalline silica can be found as both aged, and newly fractured. Newly fractured α-quartz is mainly associated with industrial processes (mining, drilling, sandblasting, glass manufacturing, Fig. 1: NASA Aqua satellite image shows a widespread sandstorm over Afghanistan that quarries and foundry work); it represents the commenced 24 August 2010 . This image was captured during the ‘120 days of wind’ period. higher health risk of the two forms, and is the http://earthobservatory.nasa.gov/NaturalHazards/view.php?id=45425 driving factor for the A2 carcinogen designation. Aged α-quartz is predominantly found in Field (KAF), Forward Operating Base Ma’Sum include wind generated desert sand as the environment and has low cancer associa- Ghar (FOB MSG) and PBSG. 69 samples were depicted in Figure 1 but also, vehicle and air- tion, but does represent a mechanical irritant taken, 24 at KAF, 18 at MSG and 27 at PBSG. borne traffic at these locations. health hazard. Sites surveyed in Afghanistan Of the 24 samples taken at KAF, 5 exceeded Some samples of the α-quartz forms of crys- (Bagram, Khowst) by the Desert Research Insti- the TLV-TWA and ranged from 26 ug/m3 to 39 talline silica taken from Afghanistan did yield tute showed no evidence of freshly fractured ug/m3. The exceedances all occurred during results that exceeded its ACGIH TLV-TWA. How- quartz grains (Engelbrecht et al., 2008). In all the evening when PM concentrations were ever, the exceedances occurred infrequently instances, quartz grains examined by the observed to be at their peak. All of the MSG and mainly during important dust events. Desert Research Institute from Afghanistan samples were below the analytical detection Therefore, considering the short deployment were consistent with environmental aged limit of 12 ug/m3. period (6–12 months compared to a lifetime of quartz and had rounded edges (Engelbrecht et Crystalline silica (α-quartz) sampling at PBSG working in an industry), the maximum α-quartz al., 2008). was conducted over three days (25–27 levels anticipated, and the fact that the bulk of Crystalline silica results from the Afghanistan August 2010) and coincided with an impor- this silica is not newly fractured but rather aged TAVs were compared to the ACGIH TLV-TWA of tant sandstorm that commenced 24 August as observed by the Desert Research Institute, 25 ug/m3 and α-quartz exceeded this health 2010, and ended on 27 August 2010. This the long-term risk posed by crystalline silica to standard on 3 separate TAVs, in 2009 and event was reported by the NASA earth’s CAF personnel deployed to Afghanistan is con- 2010 (Kandahar) and in 2011 (Kabul). The observatory and was visible from their Aqua sidered negligible. However, acute health 2009 Kandahar TAV had all air samples for satellite (Figure 1). Of the 27 samples taken at symptoms could have been expected from crystalline silica below the analytical detec- PBSG, 18 were above the TLV-TWA and in exposures to high concentration of crystalline tion limit of 12 ug/m3 except for one sample some cases, the α-quartz levels were more silica such as during sandstorms. These symp- taken at Patrol Base Sperwan Ghar (PBSG), than double the TLV-TWA. The α-quartz levels toms could have included irritation to the eyes, which produced a result right at the TLV-TWA remained high throughout the sampling nose, throat and lungs. of 25 ug/m3. This highest concentration of α- period regardless of the time of day as the quartz could have been the result of opera- high dust concentrations remained sus- Dioxins and Furans tional activities that occurred at the time of pended in the air. When the dust event sub- Dioxins and furans (D/F) are the generic terms the sampling. The firing of howitzer guns at sided late on 27 August, the α-quartz levels for polychlorinated dibenzo-para-dioxins PBSG was observed to increase both total also diminished to below or near the TLV (PCDD) and polychlorinated dibenzofurans dust and respirable dust. This would indicate values. (PCDF). D/F have no commercial purpose; that gunnery activities could be responsible With the CAF having ceased operations in they are formed as by-products of combustion for the elevated ambient crystalline silica Kandahar, the DHHAT sampled for crystalline and in many industrial processes. The main result at PBSG. silica at 5 locations in Kabul in 2011. From D/F exposure sources in Afghanistan are DHHAT conducted additional sampling in Kan- the 76 samples collected at that time, two α- likely the domestic burning of plastics, burn- dahar in 2010 with a special focus on crys- quartz samples exceeded the TLV-TWA of 25 ing of municipal waste, and combustion of talline silica due to the 2009 results. The ug/m3: one sample taken at the Kabul Inter- wood and hydrocarbons. D/F are highly per- DHHAT TAV in 2010 was purposely conducted national Airport (KAIA) of 34 ug/m3, and sistent in air and soil; they can be transported over the dusty summer months (also known another taken at Camp Eggers of 27 ug/m3. to remote areas via winds and deposited in as the ‘120 days of wind’ period) in order to The overall α-quartz average was well below soils and sediments. capture crystalline silica concentrations dur- the TLV-TWA of 25 ug/m3 as most samples There is no ACGIH TLVs or NIOSH RELs for D/F. ing their peak. Sampling occurred at three were below the laboratory detection limit of To put the Afghanistan D/F results in perspec- locations in Kandahar in 2010: Kandahar Air 12 ug/m3. The possible sources of α-quartz tive, they were compared to the Ontario ambi-

52 MCIF 3/2015 ent air quality criteria (AAQC) of 0.1 pg TEQ/m3 (MOE, 2011) and compared to concentrations measured elsewhere around the globe (Figure 2). DHHAT collected 21 D/F samples at 4 locations in Kabul in 2011. DHHAT did not collect D/F during other TAVs due to the difficulty in getting the specialised D/F sampling equipment into theatre. D/F sampling occurred in Kabul because it was felt that it represented the worst-case scenario concerning the potential presence of D/F in air. The bowl landscape surrounded by moun- tains promotes inversions and traps persist- ent compounds in air like D/F. The D/F analyses conducted in Kabul in 2011 indicated that most results were above the Canadian urban background levels and the AAQC of 0.1 pq/m3 TEQ. The results are contained between the concentrations reported in Beijing, China and Balad, Iraq (IOM, 2011; Figure 2). It is believed that these higher levels of D/F in Kabul may be the result of Fig. 2: Dioxins and furans (D/F) concentrations measured at four camps during the 2010 Kabul increased use of plastics as a fuel source for TAV in relation to Canadian urban levels from 2011, the Ontario ambient air quality criteria limits (MOE, 2011), and studies completed in China and Iraq. The levels from Beijing were averaged heating and cooking in Kabul (IOM, 2011). over three districts and the level from Balad was a ‘worst case scenario’ (IOM, 2011). Since the D/F samples taken on the 2011 DHHAT TAV to Kabul yielded results that sur- passed the health-based guideline, and thus a toxicological assessment was performed. ing acids (such as nitrates and sulfates), ferent 2013 AQI categories for PM2.5 and The toxicological assessment consisted of a organic chemicals, metals, and soil or dust PM10. D/F risk characterization conducted in two particles (US EPA, 2013). PM equal to or less ways, firstly by comparing the estimated daily than 10 μm in diameter, is known as PM10. Every DHHAT TAV completed in Afghanistan intake resulting from inhalation of Kabul air to PM equal to or less than 2.5 μm in diameter, had PM10 samples collected and analyzed published acceptable daily intakes, and sec- is known as PM2.5. Figure 3 is a graphical systematically. As research into the field of ondly, by predicting a body burden of D/F that interpretation of PM10 and PM2.5. The size of PM evolved, the importance of conducting would have resulted from the 9 month deploy- particles is directly linked to their potential for PM2.5 sampling became known and was ment to Kabul. causing health effects. Smaller particles (less implemented on every TAV from 2009 The estimated daily D/F dose for the average than 2.5 μm in diameter) are of particular con- onwards. Figure 4 depicts mean 24h-average CAF member deployed to Kabul was esti- cern because those are the particles that pen- PM results grouped for all the sites and date mated at 0.17 pg TEQ/kg bw/day or less than etrate deep into the lungs. surveyed within a given TAV in relation to the

20% of the D/F toxicity reference value of 1 pg There are no ACGIH TLV or NIOSH REL stan- US EPA AQI categories. The average PM2.5 TEQ/kg bw/day (MOE, 2011). Considering dards for PM10 and PM2.5. Thus, Afghanistan results measured throughout the Afghanistan that the conservatively estimated daily dose PM results were compared to the United TAVs fall within the moderate to the unhealthy of D/F is lower than the toxicity reference States Environmental Protection Agency (US AQI categories while the average PM10 results value even when the estimated background EPA) national ambient air quality standards extend above the hazardous AQI category. exposure to D/F is added to the calculation, for PM and their corresponding air quality The highest mean concentration for both the risk of adverse health effects for CAF index (AQI) categories. Table 2 details the dif- PM2.5 and PM10, as was the case for the members from airborne D/F in Kabul was considered to be negligible. Moreover, the pre- dicted body burden of CAF members deployed AQI Category PM2.5 mg/m3 PM10 mg/m 3 to Kabul for nine months was estimated to be ▬ Good 0 – 0.012 0 – 0.054 much lower than the body burden toxicity reference value (0.2 pg TEQ/g lipid versus 12 pg ▬ Moderate >0.012 – 0.0354 >0.055 – 0.154 TEQ/g lipid). It was therefore concluded that a ▬ Unhealthy for sensitive groups > 0.0355 – 0.0554 > 0.155 – 0.254 nine month deployment to Kabul contributed ▬ Unhealthy > 0.0555 – 0.1504 > 0.255 – 0.354 minimally to the background body burden of ▬ CAF members and no significant risk of Very Unhealthy > 0.1505 – 0.2504 > 0.355 – 0.424 adverse chronic health effects from this expo- ▬ Hazardous > 0.2505 – 0.5004 > 0.425 – 0.604 sure would be expected. Table 2. The 2013 United States Environmental Protection Agency (US EPA) National Ambient Air Particulate Matter Quality Standards for Particulate Matter and corresponding color-coded Air Quality Index (AQI) (US Particulate Matter (PM) is a complex mixture EPA, 2013). of small particles and liquid droplets. PM is Notes: made up of a number of components, includ- PM10 = PM equal to or less than 10 μm in diameter PM2.5 = PM equal to or less than 2.5 μm in diameter

MCIF 3/2015 53 α–quartz form of crystalline silica, occurred during the 2010 TAV to Kandahar during the ‘120 days of wind’ period. The highest levels of PM and silica during the 2010 TAV to Kan- dahar were temporally associated with dust events as shown by the NASA satellite imagery (Figure 1). Based on the air quality surveys, CAF members deployed to Afghanistan were potentially

exposed to PM2.5 and PM10 at concentrations sufficient to pose a short-term health risk such as eye irritation, nose, throat and respiratory symptoms such as cough and sputum production. While these symptoms were possible during general ambient conditions in Afghanistan, they were probable during a dust event, when the majority of personnel (whether healthy or predisposed), could be expected to demonstrate some symptoms and those with pre-existing respiratory condi- Fig. 3: Graphical interpretation of PM10 and PM2.5. Image courtesy of the US EPA. tions such as asthma could be expected to experience worsening of their symptoms. Although acute air quality related symptoms while deployed were probable, it is unlikely that the exposure to infrequent, short-term dust events would produce long-term health effects. There is little evidence in the scientific literature to support clinically significant delayed onset or long-term health effects following high exposures to PM during a relatively short-term deployment (6 to 9 months). However, research in this field is limited as large, long-term studies are required and the unusual patterns of potential exposure (per- taining to a 6 to 9-months military deployment) are relevant to only a very small group of people. The majority of the PM research has focused on the adverse health effects on the general population over a long-term exposure to ultrafine urban fossil fuel derived PM, which has been associated with increased cardio-pulmonary disease and mortality. The US EPA AQI is based on this health research. There is less research and knowledge about the long-term effects of short-term exposure to high levels of PM in relatively healthy troops. This makes the interpretation of exposure limits and health risk assessments a challenge. On-going research mainly from the US Army Public Health Command pulmonary working group will hopefully shed light on these issues. A review of the EpiNATO and Disease and Injury Surveillance System (DISS) data reflecting the time of the dust event in 2010 did not indicate any rise in clinic/hospital visits for respiratory illness. However, this lack of association could also reflect the difficulty in establishing transient PM-related health effects to short-term PM exposures. Exposures to high PM levels during dust Fig. 4: Mean 24h-average particulate matter (PM) concentrations for each Afghanistan technical events can be mitigated by personnel reduc- assistance visit (TAV) in relation to the 2013 United States Environmental Protection Agency (US ing heavy outdoor activities as well as by EPA) Air Quality Index (AQI) categories. The lines are the top breakpoints of the corresponding moving indoors. This change in activity was color-coded AQI category. The error bars are the standard deviations.

54 MCIF 3/2015 promoted, in the Afghanistan deployed setting, by the cessation of air operations in times of poor visibility, which in turn resulted in cessation of patrols. Conclusion Over the 11 years of ambient air quality results from Afghanistan, thousands of samples were taken from various compounds or groups of compounds; PM, crystaline sillica, asbestos fibres, VOCs, metals, elemental carbon, PAHs, D/F, sulfur oxides, nitrogen oxides and ozone. Based on all the monitoring and the sampling conducted, three analytes were identified as compounds of potential concern to CAF members deployed in Afghanistan; D/F, crystalline silica and PM. The D/F toxicological assessment revealed no significant risk of adverse chronic health effects would be expected. However, CAF members’ exposures to PM and crystalline silica were, at times, enough to pose acute health effects such as eye, nose, and throat irritation as well as respiratory symptoms. Although there is currently little scientific evidence to support clinically significant delayed- onset or long-term health effects following these sporadic high exposures, research in this area is limited and still ongoing, making definitive interpretation of health risk assessments a challenge. Final Remarks Visit us at the ERC DFHP employs DHHAT in a variety of ways, and DHHAT’s role is a diverse in Prague one that spans beyond air quality monitoring. DHHAT was activated for 29.–31.10.2015 booth A12 various TAVs in the recent years; in the aftermath of the Haiti earthquake in 2010, in 2013 to Israel and in 2015 to Kuwait. DHHAT also fulfills domestic taskings such as providing support to OP NANOOK in the Cana- dian Arctic for Joint Task Force North, and completing occupational and SCHILLER is your strong partner environmental health surveys for the Submarine Safety program. For additional information on DHHAT, its role and publications, visit the following for rescue questions CAF Health Services Website: http://cmp-cpm.mil.ca/en/health/personnel-providers/deployable-health-hazard-assessment-teams.page. n References: [email protected] ARGUS PRO LIFECARE 2 Deﬁ brillator, pacemaker, patient monitor and 12- AUTHORS channel ECG in a compact nnJanickCreating D. a Lalonde, national trauma PhD registry and design. Whatever the Dr.computerization, Lalonde holds a specialisedcurrently lacking, Master’s needs degree in requirement – emergency Chemicalto be looked and at. Environmental Toxicology and a care, interhospital or Doctoral degree in water sciences for which she in-house patient transfer – won the Governor General Gold Medal. Following her graduate studies, Dr. Lalonde was hired by the Department of Natio- the APLC2 assists nal Defence as the Senior Advisor in Toxicology within the Directorate of you without compromise. the Force Health Protection of the Canadian Forces Health Services Group. In this capacity, and with the help of a multidisciplinary team, DEFIGARD TOUCH 7 Dr. Lalonde conducts environmental health risk assessment for CAF members in garrison and in deployed settings. She is passionate about A compact combination her work and enjoys sharing her enthusiasm by teaching graduate students as well as Medical Officers from the Canadian Armed Forces. of state of the art deﬁ brillation technology Address for the authors: and comprehensive Janick D. Lalonde, PhD monitoring functions. Senior Advisor – Toxicology, Directorate Force Health Protection Department of National Defence Minimum weight, maxi- Government of Canada mum performance and [email protected] ultimate touch experience. Tel: 613-945-6600 x 3176 First and corresponding author

CO-AUTHOR Capt Monica Bradley DHHAT Team Leader, Directorate Force Health Protection

Headquarters: SCHILLER AG, Altgasse 68, CH-6341 Baar, Phone +41 41 766 42 42 MCIF 3/2015 Fax +41 41 761 08 80, [email protected], www.schiller.ch INTERNATIONAL CONFERENCE ON DISASTER AND MILITARY MEDICINE

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Attacks on major events present rescue staff with special challenges. The attack on the Boston Marathon killed three people, another 250 were injured, some of them severely. In a situation like this, civilian and military relief and rescue units must co-operate very closely. Contributions to this topic will be discussed on this year’s DiMiMED.

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MCIF 3/2015 57 DIABETES – SEPTIC FOOT AMPUTATIONS

H.M.H.TAYSEIR, M. EL M. OSMAN, A.A.M. HASSAN (SUDAN) Amputations in Patients Admitted with Diabetic Septic Foot Wad-Medni Teaching Hospital (2008 – 2009)

Hospital based and general population based data of the burden of diabetic foot disease in Sudan are scanty. Accurate information on the prevalence of the risk factors for diabetic foot ulceration is also much needed, as it is essential for developing and evaluating preventive procedures, public health practices and health care services.

Abbreviations D.M. Diabetes Mellitus DSF Diabetic Septic Foot 31% ESRF End Stage Renal failure MULTIPLE H/O History Of Amputated JDC Jabir Abu Aliz Diabetic Center 43% Not Amputated LEAs Lower Extremity Amputations SINGLE 69% 57% LOS Length of Stay MLEAs Multiple Lower Extremity Amputation NOGs Non Government Organizations Pt. Patient Fig. 2: H/O AMPUTATION INCREASES THE RISK RBS Random Blood Sugar FOR ANOTHER AMPUTATION SPSS Statistical Package Program for Social Science Fig. 1: AMPUTATION RATE AMONG PT. risk of LEA was significantly associated with U/S Ultrasound ADDMITTED TO SURGICAL WARDS WITH D.S.F the grade of ulceration at presentation, UT UT University of Texas staging, other co-morbidities, increasing age uary 1st 2008 to December 31st 2009 (study and gender. The mortality rate was 3.7 %. The period). Detailed clinical data were recorded outcome of ulceration was determined by the for each patient, followed by a comprehensive severity and grade of foot ulceration at pres- physical examination. Clinical outcome was entation. Despite a significant proportion of Introduction documented and analyzed using the statisti- patients having an underlying neuro-ischemic The prevalence of lower extremity amputation cal package program for social science etiology for foot ulceration, the majority (LEA) is high in Sudan, but the underlying risk (SPSS).The results were tabulated and pre- healed and the need for LEA did not arise. factors remain to be defined. This study aims sented in percentage forms. A total of 81 There was gender difference in risk for under- at determine the pattern of amputations in patients were studied. Nine patients (11.1 %) going LEA, which was higher in male patients. diabetic patients admitted with septic foot had grade one, 54 patients (66.7 %) had The risk for LEA also increased with age. The and to explore the prevalence rate, types, grade two and 18 patients (22.2 %) had grade situation is more challenging in developing clinical features and possible risk factors and three ulceration according to university of countries due to limited resources so that clinical outcome in diabetic patients with sep- Texas(UT) classification system. 46 patients more stress should be given to prevention, tic foot admitted to Wad-Medani Teaching (56.8 %) were managed without the need for patient education, and the establishment of hospital, Wad-Medani, Sudan. This is a lower extremity amputation (LEA), 35 pa - multidisciplinary teams in small diabetic units prospective descriptive cohort study of newly tients (43.22 %) underwent LEA. 17 patients that disseminate and apply the international hospitalized, adult diabetic patients with sep- (20.99 %) underwent major LEA while 18 guidelines on the management of the diabetic tic foot conducted during the period from Jan- patients (22.23 %) underwent minor LEA. The foot.

苏丹基于医院和一般人群的糖尿病足病负 Les données basées sur les hospitalisa- Данные о серьезности проблемы диа- Los datos basados en la población 担数据寥寥无几。还急需糖尿病足溃疡风 tions et sur la population en général du бетической стопы в Судане скудны - general y en los hospitales de la carga 险因素发病率的准确信息，因为这是制定 poids des maladies de pied dues au dia- как на уровне данных лечебных учреж- de enfermedad de pie diabético en 和评估预防程序、公众卫生习惯和卫生保 bète au Soudan sont insuffisantes. Une дений, так и в целом для всего населе- Sudán son escasos. La información 健服务不可或缺的一部分。 information précise quant à la prévalence ния. Столь же велика необходимость в precisa sobre la prevalencia de los fac- des facteurs de risque d'ulcération du точной информации о распространен- tores de riesgo de la ulceración del pie pied diabétique est un besoin important, ности факторов риска диабетической diabético también es muy necesaria, ya de même qu'il est essentiel de développer язвы стопы, а это крайне важно для que es esencial para desarrollar y eva- et d'évaluer les mesures de prévention, les разработки и оценки профилактиче- luar procedimientos preventivos, prácti- pratiques de santé publique et les services ских процедур, практики обществен- cas de salud pública y servicios de de soins. ного здравоохранения и медицинских atención sanitaria. услуг.

58 MCIF 3/2015 TYPES OF AMPUTATIONS

14% 8% 20%

29% 23% 92% 8% 6%

Fig. 3: REAMPUTATIONS Above knee Below knee Sym's Trans metatarsal Ray's Minor toe

Fig. 4: Types of amputation Patients and methods This is a prospective, descriptive cross sec- Data collected included age, sex, type/dura- tional hospital based study. It was conducted tion of diabetes, cause of ulceration, duration at Wad Medani teaching hospital, which is a of ulcer, previous history of ulceration, pre- (300) bedded tertiary level hospital receiving senting signs & symptoms and previous treat- referrals from various localities of Al Gezira ment and socio-economic status. Diabetes state and surrounding states. There are five control was assessed based on the fasting 60% (5) surgical units; each is headed by a con- (FBS) & random (RBS) plasma glucose levels. sultant, (2 – 4) registrars and (8– 12) house FBS <120mg/dl good, 121 – 140 mg/dl, fair officers. There is a daily referral clinic run by a and >140mg/dl, poor. For RBG values surgical unit. The hospital theatre has four (4) <160mg/dl, good, 160-180mg/dl, fair rooms for general surgery and one room for >180mg/dl, poor. laparoscopic surgery. The study population The examination of the diabetic feet followed Fig. 5: INDICATIONS FOR AMPUTATIONS included all patients (81) admitted to the sur- the recommendations of the American dia- gical wards with diabetic septic foot, from Jan- betes association (ADA). uary 1st 2008 to December 31st 2009. All Each patient underwent assessment of the All foot ulcers were photographed at the initial patients were consented to participate in the vascular status by manual palpation of presentation and at each stage of review study. femoral, popliteal, dorsalis pedis and poste- through the study. Outcome is recorded as: No rior tibial arteries to define patency and grade: amputation or LEA defined as loss of any part Inclusion Criteria (a) good volume (b) diminished volume or (c) of the lower limb as major if proximal to tarso- 1. All patients admitted to surgical ward. absent. Neuropathy was quantified assessing metatarsal joint and minor if distal to this joint. 2. Aged 18 years and above. vibration sensation using a 128 HTZ tuning All collected data were finally entered in the fork and a 10 g monofilament applied perpen- computer using the statistical package pro- Exclusion Criteria dicularly to the plantar aspect of the first toe, gram for social science (SPSS). 1. Patients managed at the outpatient clinic the first, third and fifth metatarsal heads, the or at home. plantar surface of the heel and dorsum of the Objectives 2. Private Patients. foot avoiding any callosities, corn or wound Main objectives: 3. Young patients below 18 year of age. site and graded as normal, diminished or To study the pattern of amputations in dia- A full detailed history was taken from each absent. Ankle and knee reflexes were betic patients admitted with septic foot. patient and a proper systemic examination assessed as normal, reinforced or absent. was performed by the author, together with Osteomyelitis was determined by radiological Specific objectives: relevant investigations. examination. The University of Texas Classifi- To study: All patients were assessed further for ischemia, cation System was used to classify the sever- nn Prevalence of DSF related amputations. neuropathy, grade of ulcer, infection and asso- ity of ulceration at pre sentation. nn Types of DSF related amputations. ciated complications (e.g. renal function The treatment provided covered these aspects: nn Clinical features of DSF related to amputa- impairment, sepsis, hypertension…etc.) nn Surgical debridement (figure 16) tions. Data were collected after obtaining consent nndressing nn Possible risk factors for DSF leading to from all patients using a pre-designed data col- nn Control of infection amputations. lection sheet which was constructed in sections nn Control of diabetes nn Relation to age and sex. to address different aspects of the problem: Section (1): Personal data. AGE IN 20 30 40 50 60 70 80 Section (2): Diabetes history. YEARS to to to to to to to Section (3): Chronic illness history. 29 39 49 59 69 79 99 Section (4): Investigation. NO.OF 3 7 13 23 24 9 2 Section (5): Treatment. IN-PT.s Section (6): Complications. Section (7): Rehabilitation. Tab. 1: Distribution of pt.s into age groups

MCIF 3/2015 59 nn Survival after amputations (peri opera- advanced stage of foot ulceration with a tive).- 7 resultant high amputation rate (43.2 %) in nn The need for a different approach to deal agreement with several other studies. Further- 6 with the problem of DSF in our community. more, male subjects had a greater chance of nn Patient awareness of the role of prevention. 5 undergoing LEA than female subjects as

shown in other studies. Patients with neu- 4 Results ropathy and ischemia were more likely to amputations f

3 o The total number of patients involved in the . undergo LEA but neuropathy alone was not study was 81. The mean age for the study No independently associated with LEA, as shown 2 population was 55.5 years; the majority of in a number of other studies. Analysis showed

patients (71 %) had type 2 diabetes mellitus. 1 that beside age, hospital admission was inde- Most of the patients (83.5 %) presented with pendently associated with LEA. Clearly this is 0 foot ulcers. Nine patients (11.1 %) had grade 81 79 77 75 73 71 69 67 65 63 61 59 57 55 53 51 49 47 45 43 41 39 37 35 33 31 29 27 25 23 2119 17 15 13 11 9 7 5 3 1 related to more advanced grade and stage of Age one, 54 patients (66.7 %) had grade two and ulceration requiring hospitalization for intra- 18 patients (22.2 %) had grade three ulcera- Fig. 6: RISK OF AMPUTATION INCREASES WITH venous antibiotics and surgical intervention tion. 46 patients (56.8 %) were managed with- AGE leading to LEA. out the need for LEA, 35 patients (43.2 %) Patients with previous history of limb amputa- underwent LEA (Figure: 1). Nearly 21 % of Anemia was common among admitted tion were at a higher risk for amputation, rep- patients underwent major LEA while 22.23 % patients (27.16 %) representing an important resenting 31 % of amputees. of patients underwent minor LEA. The risk of risk factor for amputation as 45.71 % of the Compared to our hospital, Jabir Abualiz Dia- LEA was significantly associated with the amputees were anemic (Figure: 7) .On the betic Centre (JDC), Khartoum reported a lower grade of ulceration at presentation, UT stag- other hand, 72.73 % of the anemic subjects amputation rate of 38 % among patients ing, other co-morbidities, increasing age and were amputated. admitted with diabetic foot according to world male gender (Figure: 6). The mortality rate Few (10.5 %) patients had critical limb diabetes foundation, Sudan project. was 3.7 %. Inflicting cause was identified in ischemia as determined by Doppler U/S scan. The majority of patients presented with (40.4 %) of the patients. The most commonly This was found to be the most significant risk advanced stage and grade of ulceration affected toe was the big toe in 39.0 % of the factor for major amputations. reflecting a lack of structure in the health care patients, followed by the second toe in There was no association between LEA and delivery system of Sudan between primary, 18.5 % of the patients. The plantar aspect of poor glycemic control as 45.71 % of the secondary and tertiary care units. Attempted the foot was affected in 42.6 % of the patients amputees were on regular diabetic follow-up home surgery, trust in traditional and faith whereas only the heel was involved in 10 % of (Figure: 8, table 2).This can be explained by healers and undetected diabetes further the patients. Dorsum of the foot was involved the fact that most of the patients have poor aggravates the problems. Moreover, inade- in 13.6 % of the patients. diabetic control. It was noted that six out of quate antibiotic treatment and the use of non- The mean duration of diabetes among patients eight newly discovered diabetics were ampu- sterile instruments for dressing, results in the who underwent amputation was 16 years. tated (75 %). growth of multi resistant organisms necessi- It was recorded that 43.2 % of patients had Significant number of patients (57 %) did not tating hospital admission and surgical inter- different types of amputations. (Figure: 1) receive foot care advice at the time of diagno- vention. This will also contribute to increase 20.99 % of the patients had major amputa- sis of diabetes, which is an important preven- the length of stay (LOS) in the surgical wards, tions. Above knee amputations were reported tive measures (Figure: 9). causing additional pressure on the health in 6.17 % of the patients, below knee amputa- This study recorded that 97 % of patients services. tions and Sym’s amputation represented were of low socio-economic class, neverthe- These poor outcomes also reflect the low 12.35 % and 2.47 % of the patients respec- less only 14 % of them were covered by health priority in terms of health spending. Only 2 % tively (Figure 2). insurance! to 5 % of the total household expenditure is It was recorded that 22.23 % of the patients spent on health, while the required amount is had minor amputations. Toe amputation was Discussion much higher.3 Most of the patients (97 %) reported in 8.64 % of the patients, Ray’s Diabetic foot ulceration is the most frequent come from a low socio-economic back ground amputation and trans metatarsal amputations cause of hospitalization among diabetic and therefore can not meet the demands of were recorded in 9.88 % and 3.71 % of the patients. LEA, is the most feared and costly treatment (dressing material, drugs, investi- patients respectively. consequence of foot ulceration. In this study gations… etc) which are usually required for History of lower extremities amputations was the majority of patients presented at an long periods of time. They need financial sup- present in 13.58 % of the patients. This group represented 31 % of the amputees (Figure: 2). Others A re-amputation rate of 8 % was reported 13% Malaria AnemiaAnaem (Figure: 3). 5% i 33 The toes were the most commonly amputated % in 18.52 % of the patients (Ray’s and minor toe amputations) and accounted for 43 % of

total amputations (Figure: 4). Nephropathy Gangrene was the commonest indication for 15% amputation (59 %), followed by osteomyelitis Death 5% 23% (Figure: 5) Hypertension D.K.A. The risk for amputation increased with age. Stroke 13% 3% 13% Maximum amputations occurred between ages of 54 to 70 years (figure: 6). (table: 1) Fig. 7: Common complications associated with D.S.F.

60 MCIF 3/2015 Regular follow up Neglected Newly discovered Pt.s admitted with DSF 51 (62.96%) 22 (27.16 %) 8 (9.88%) Amputated Pt.s 16 (45.71%) 13 (37.14%) 6 (17.14%) YES Amputation 31.37% 59.09% 75% 43% NO Tab. 2: FOLLOW-UP AND CONTROL OF D.M 57% port, which they seldom get. Unfortunately, the fact that all these patients had poor gly- only 14 % of them are covered by health caemic control. It is of interest that 17.14 % of insurance which is meant basically to support LEAs were performed in persons newly and the poor and needy sections of the society. recently diagnosed as having diabetes. More- This issue needs to be addressed by the over, six out of eight newly discovered diabet- Fig. 9: FOOT CARE ADVICE authorities taking in consideration the serious ics (75 %) underwent a sort of LEA. It would consequences of neglected D.S.F, the scale appear, therefore, that some patients pre- major deficiency in this study is that it is not and the impact of this problem on the com- senting with established foot complications population based and represents patients munity. of diabetes would not be able to benefit from referred to a tertiary care center. However, it The mean duration of diabetes among secondary preventative health care. has the advantage of accurate characteriza- patients who underwent amputations was 16 Anemic patients were at greater risk for ampu- tion of the stage and severity of foot ulcera- years. This explains the increased risk for tations as 72.73 % of them underwent L.E.A., tion with a high follow up rate. Earlier presen- amputations associated with aging. The peak representing 45.71 % of the amputees. Ane- tation with aggressive and appropriate incidence of amputation occurred at the age mia will complicate the ischemic state of the medical and surgical treatment according to of 55 to 75 years. diabetic foot and delays healing, therefore if the severity of ulceration can improve morbid- In this study, there was no association present, anemia should be corrected immedi- ity and reduce mortality. This can be achieved between LEA and poor glycemic control as ately. by educating health care professionals and shown in other studies. We noticed that The current study confirms a high amputation patients through education programs and patients with neuropathy underwent LEA inde- rate as a consequence of diabetic foot ulcera- instituting comprehensive multi-disciplinary pendent of poor diabetic control. This reflects tion in Wad-Medani teaching hospital. The foot care programs. At the patient level, effec-

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MCIF 3/2015 61 nent and sufficient causes. Component causes are risk factors that are insufficient by themselves to cause the outcome of interest (LEA or ulceration) but are required components of a complete causal pathway that is sufficient to produce the outcome. A sufficient cause, therefore, is a constellation or grouping of the minimal number of specific component causes that, in concert with each other, inevitably produce disease. There can be a number of sufficient causes with various combinations of component causes that produce the same outcome. However, removal of any component Fig. 8: History of diabetic follows up among amputees cause will block the completed pathway to the sufficient cause and thereby prevent disease tive foot care advice should be propagated to throughout the country. „We can and should through this specific pathway. reduce the burden imposed by diabetic foot begin to follow the examples set before us. A study conducted in Nigeria reported LEA complications, particularly in developing We must not wait till the present situation rate of up to 50 % among patients admitted countries. The implementation of these meas- reaches catastrophic proportions before we with diabetic septic foot to a tertiary health ures has led to a 77.8 % decrease in amputa- begin to act”. care center5, while the rate was 27.5 % in tion rates amongst persons with diabetes in A study conducted at Jabir Abu Eliz Diabetic another study conducted in Pakistan4 Brazil where ‘Save the Diabetic Foot Project‘ Center (JDC), University of Khartoum, Imple- (Figure: 12 – 16) has been implemented. This shows that even mented a system for prediction of lower in resource-poor countries Strategies can be extremity amputation.7 Conclusions put in place to improve the outcome of dia- They used the criteria for wound classification Hospital based and general population based betic septic foot without the need for expen- adopted by the International Consensus for data of the burden of diabetic foot disease in sive equipment. In parts of India and in Brazil, the Diabetic Foot to get a reliable grading of Sudan are scanty. Accurate information on the careful screening of patients, education of the the diabetic foot and predict the outcome. prevalence of the risk factors for diabetic foot patient and health professionals and the These criteria were: the degree of limb ulceration is also much needed, as it is essen- institution of preventive measures have been ischemia, sensory neuropathy, depth and sur- tial for developing and evaluating preventive successful in reducing ulceration and ampu- face area of the wound, severity of sepsis, procedures, public health practices and tation rates. These successes are heartwarm- and ESRF. health care services. ing and should encourage us. Our ultimate Risk factors for diabetic LEA, based on several The prevalence and outcome of diabetic foot target should be to make available effective types of analytic studies, are quite similar to disease are influenced by genetic factors, cul- preventative foot care and education pro- those for foot ulceration. In fact, foot ulcera- tural factors, and the quality and availability grams that will work effectively in primary, tion itself seems to be a major predisposing of health care services. Lack of proper health secondary and tertiary health care settings risk factor for LEA, preceding approximately education, knowledge and skills by both 85 % of amputations. Most studies indicate patients and health care providers, as regards that duration of diabetes, level of diabetic the care of the diabetic foot, still results in control, and various degrees of neuropathy insufficient prevention and management. For are independent predictors for amputations, many people access to health care is still very as are blood pressure, retinopathy, nephropa- limited, with a great number of patients pre- thy, and peripheral vascular disease. Ciga- senting very late to hospital. rette smoking is an inconsistent risk factor The low socio-economic status and unsatis- across a variety of study designs. factory diabetic control of many patients are In their landmark paper, Pecoraro et al deter- significant contributory factor to the high mor- mined the causal pathways responsible for bidity and mortality associated with diabetic LEAs in a series of consecutive male diabetic foot ulcerations. Delayed referrals to second- patients. ary and tertiary centers by medical practition- Fig. 12: Typical diabetic foot ulcer caused by Using the model established by Rothman, the ers are also common. Unfortunately, even in high plantar pressures at the third metatarsal causal sequence was defined by both compo- tertiary hospitals in Sudan, inadequate facili- head ties and socio-economic burdens also hinder prompt and appropriate treatment. Presently, there are no podiatrists, orthotists or specialized foot clinics. Most tertiary centers are not even equipped for vascular intervention. There are also no facilities for customized footwear, and offloading devices. The inade- quacy (or sometimes total lack) of foot care program provisions at primary and secondary health care settings is a considerable barrier to the provision of foot care for patients with diabetes mellitus. This emphasizes the need Fig. 15: Below knee amputation Fig. 16: Surgical debridement of D.S.F. for the provision of foot care programs, not

62 MCIF 3/2015 just at tertiary level, but also at primary and throughout the country. This leads to the secondary health care levels. provision of sufficient interested and AUTHORS To reduce the amputation rate, however, trained personnel. attention should be paid through a multidisci- 3) To enhance preventive measures and pro- Tayseir plinary setup to timely referral from the physi- vide adequate education facilities for peo- Hamid Moh. cian, patient education, total contact cast, and ple with diabetes and their families. The Lt. Col. MC, Sudanese appropriate revascularization. The situation is golden rule: „prevention is better than Armed Forces more challenging in developing countries due cure”. General surgeon, to limited resources so that more stress 4) Introduction and implementation of hospi- Omdurman military hospital should be given to prevention, patient educa- tal based specialist multidisciplinary foot Graduated (MBBS) from Dr. Ambedkar tion, and the establishment of multidiscipli- care clinics and the addition of orthotists medical college, Bangalore University, nary teams in small diabetic units that dissem- to the team. These teams are to be built up India, MD (General Surgery), inate and apply the international guidelines step by step, introducing the various disci- Gezira University, Sudan on the management of the diabetic foot. plines at different stages 5) To establish multidisciplinary care and the Address for the authors: Recommendations integration of work between the orthotists E-mail: [email protected] The situation of diabetic foot care in Sudan is and nurses. First and corresponding author not satisfactory, resulting in high LEAs rates 6) Expansion of the national health insurance with major economic consequences for the coverage to include and cover the weaker CO-AUTHORS Osman Mohammed El Mustafa patients, their families, and society and have and low socio-economic sections of the Professor of surgery (ENT), a huge impact on health services. In order to society. This service should provide the faculty of medicine, university of Gezira tackle this growing problem we recommend necessary support for rehabilitation of Hassan Ali Ahmed Musa the adoption of the following measures: amputees. Professor (associate) of general surgery, 1) Policy makers should understand the dev- The time has come for a concerted effort to faculty of medicine, university of Gezira astating effects caused by diabetic foot provide foot care programs for patients with problems and the urgent need for an inte- diabetes mellitus. Governments, other health grated DSF care program in primary, sec- control agencies and non-government organi- and foot care programs can be allocated. A ondary and tertiary health care settings. zations (NGOs) need to be made aware of the concerted effort must be made towards 2) Training health professionals in foot importance and suffering relating to diabetes obtaining nationwide epidemiological data on examination techniques and diabetic foot mellitus and diabetic foot problems, so that the burden of diabetic foot disease. n care at health centers and hospitals proper resources for diabetes education, care References: [email protected]

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L. NIKOLLARI, E.NIKOLLARI (ALBANIA) Epidemiological Profile of Trauma University Hospital Trauma & Military Hospital in Tirana, Albania

Nowadays the “epidemic of trauma” is evident in Albania, its treatment in the University Hospital of Trauma and Military Hospital (UTHMH) remains of primary importance. The statistical data and the volume of work as described in this article, give a full profile of UTHMH as a tertiary hospital that treats trauma at a national level.

Introduction University Hospital of Trauma & Military Hos- pital (UHT&MH) is a continuation of the Cen- tral University Military Hospital (CUMH coming). By government decision from January 2013 UHT is depending from the Ministry of Health. Military medical personnel is dependent from the Ministry of Defense, but is included in the structure of trauma and is part of the mission. UHT&MH is a tertiary hospital, the second in the country, qualified for the mission “trauma management at the national level”. UHT&MH has the following specialties: basic services, Emergency, Surgery, Orthope- dics, Neurosurgery, ENT, Ophthalmology and Maxillofacial, ICU, Reconstructive Surgery, Therapy and Rehabilitation services. It has a capacity of 192 beds, but in emergencies, dis- Chart 1: Number of killed per million populations, 2012 Source: SEETIS III, IRTAD (*data 2011) asters and catastrophes the capacity can be extended to 250 beds. The total personnel is 321 (81doctors, 200 nurses and technician munitions in Gërdec 2008 (Picture 3,4) and period 2010–2014, which include emergen- pharmacists plus 40 for administration & the bus crash with students in south, Himara cies, admissions, operations, automobile logistics). The history of the UHT&MH as the 2009 (Picture 2,5). accidents analyzed in an analytical manner National Trauma Centre since 1993, reflects arranged in tables and graphics, subject to some culminating moments in emergencies UTHMH is located in a strategic position close statistical analysis to determine indicators for and disasters - such as the treatment of to the crossing of the national road north- a rate of change. wounded in riots in 1997 in Albania, during south, which makes possible the transporta- the Kosovo war in 1998-1999, the car crash tion of the wounded in a car accident on time. General Remarks with students from Kosovo 2004 in Fushe- Methods: Study material consists of all statis- In the world today, trauma occupies a special Arez, treating injured by the explosion of tical cases presented in UHTMH for a five-year place with a growing trend and due to high

如今，“流行外伤”在阿尔巴尼亚是普遍现 De nos jours "l'épidémie de traumatismes" В настоящее время налицо «эпидемия Hoy en día, la "epidemia del trauma- 象，其治疗在University Hospital of est évidente en Albanie, son traitement à травм» в Албании. Соответствующая tismo" es evidente en Albania y su tra- Trauma and Military Hospital医院（ l'Hôpital Universitaire du Traumatisme et терапия в Университетской больнице tamiento en el Hospital Universitario de UTHMH）仍然占有最重要的位置。本文 Hôpital Militaire (UTHMH) reste de pre- травматологии и военного госпиталя Traumatismos y Hospital Militar 所述的统计数据和工作量详述了UTHMH mière importance. Les données statis- (UTHMH) остается делом первостепен- (UTHMH) es de suma importancia. Los 作为三级医院按照国内水平治疗创伤的情 tiques et le volume de travail décrits dans ной важности. Статистические данные datos estadísticos y el volumen de tra- 况。 cet article, donnent un profil complet de и объем работы, описанные в этой bajo según se describen en este artí- l'UTHMH en tant qu'hôpital tertiaire trai- статье, полностью отражают специали- culo proporcionan un perfil completo tant les traumatismes au niveau national. зацию UTHMH как третичной боль- del UTHMH como hospital superior que ницы, где проблемы травматологии trata el traumatismo a nivel nacional. рассматриваются на национальном уровне.

64 MCIF 3/2015 rate of death with impact on society and the economy. Every year in the world are estimated about 5-6 million people who die as a result of trauma. Trauma affects the produc- tive part of society, the young. At ages between 0-45 , trauma is calculated second behind HIV / AIDS as a cause of death. Head trauma takes the first place in early and later mortality.

The road safety is among the most debated issues worldwide as road traffic deaths and injuries are considered a major public health and development issue. More than 1.2 million people are killed and up to 50 million are injured, every year, in road crashes. The World Health Organization's Global Status Report on Road Safety, 2013, recognizes road traffic injury eighth leading cause of death globally.

Current trends suggest that road traffic Chart 2: Number of killed per million motor vehicles, 2012 Source: SEETIS III, ETSC injuries will become the fifth leading cause of death by 2030, unless urgent action is taken. Half of the world’s road traffic deaths occur YEARS TOTAL SYRGERY INTERNAL MEDICINE among vulnerable road users, including 2010 42336 (21%) 24849 (21.5%) 17487 (19 %) motorcyclists (23%), pedestrians (22%) and cyclists (5%). In charts 1 and 2 Albania rates 2011 38812 (19.7%) 22173 (19.2%) 16639 (18.1%) very poorly in both indicators, compared with 2012 32739 (16.5%) 19312 (16.7%) 13427 (14.6%) other countries. Limited road safety consti- 2013 44481 (22.5%) 22100 (19.1%) 22381 (24.3%) tutes a major problem for Albania, as the number of road crashes with either fatal casu- 2014 38691 (19.6%) 26847 (23.2%) 11844 (13%) alties, serious or light injuries have increased Total 197059 (100%) 115281 (58.5%) 91778 (46.%) significantly over years. AM 39411 ˜40.000 ˜24.000 ˜17.000

Tab.1 During the period 2010-2014 medical Tab. 1: Emergency Case 2010-2014 emergencies occupied a significant place where are counted 40,000 patients per year AGE SEX No DATA TOTAL % (averaged over 100 per day) and the main 0-14 14-30 >30 M F share of surgical emergencies 59-60%, the 1 TOTAL CASES 27 44 105 87 89 176 100 rest are therapeutic urgency. (Table 1). 2 VLC 99 56.2 According to the census in medical emergen- 3 FRACTURES 20 11.3 COMMOTIONS & cies during the past three years, etiology of 4 43 24.4 CONTUSIONS trauma in UTMH emergency are: 5 ARM AMPUTATION 1 1 1 0.5 nn Car accidents ...... 12% 6 DIFF. BURNS 13 7.3 nn Gunshot wound...... 4.8% 7 TOTAL (2+6) 176 100 nn Work trauma ...... 38.8% 8 HOSPITALIZED 66 100 nn Wound caused by Greece 6 9% Italy 4 6% blind and sharp tools ...... 19.4% 9 EVACUATED ABROAD Turkey 1 1% TOTAL 11 16.6% During Ammunition Explosion in the demoli- Statistical Data, Ammunition Explosion GERDECI-2008 tion center in Gërdec on march 15, 2008 at 12:15 h, 10 km NW of Tirana, near the Tirana- Durrës national highway, in a distance of 3-4 nia as well. While efforts are made in years to km from National Airport (Foto), Just at the make the roads safe, data show that crash moment of explosion, 26 persons were dead victims are of huge concern for the Albanian (Picture 3). In less than two hours UTHMH public health. Chart 3 show the trend of all received 176 wounded with severe medium types of road crashes, number of casualties and heavy injuries, which were managed pro- and fatalities. During the last five years fessionally by medical personnel. The Gerdec (2009-2013) fatalities have remained within a case shows that a trauma hospital can be band ranging between 300 and 390 per year, confronted at any moment with trauma of equivalent to a rate of between 10 and 12 tragic proportions. fatalities per 100,000 persons. However, from 2009, the number of those seriously injured is The issue of road traffic crashes and the high increasing every year compared to fatalities Chart 3: Number of crashes, casualties and fatalities, by year Source: INSTAT Albania number of victims is highly debated in Alba- (chart 4).

MCIF 3/2015 65 There are 5000 to 6000 patients per year at UHTMH where the traumatic surgical admission predominates by 84% and therapeutic by 16 %. Surgical interventions are 53 %. The Hospital conducted 600 operations per year and 28-30 thousand microsurgery interventions.

This data is typical for a national emergency hospital as well as fora traumatic surgical hospital.(Tab.2)

Data for basic morbidity show that cases of “trauma” hospitalized are 40.3% of surgical and 51% of emergencies that occur in the Chart 4: Number of road crash victims by type of injury and year hospital. Head trauma has higher figures, Source: Ministry of Transportation and Infrastructure, Annual Report on Road Safety, 2013 38%, fractures 20%, 15.3% abdominal trauma. By age group at 74.5% are active ages 15 to +65 years, at 74% are males and INTERVENT & 26% females. With an incidence 61-62 per RECOVERY YEARS % INTERVENT % MICROSURGERY IN (Surgery & Internal) thousand (Tab.3) EMERGENCY 2010 7423 24.8 3739 50.4 2011 6023 20 2993 49,7 Based on the number of recoveries and regis- 2012 5770 19.3 2870 49.7 600 tered deaths, the total mortality in UTMH is 2013 4863 16.2 3117 64 Surgery intervene 2.2%, while in ICU the average mortality in the 2014 5827 19.4 3158 54.1 28-30.000 29906 Microsurgery years of the survey showed 18%. This is due Total 100% 15877 100% (25048-4858) to the fact that cases treated in intensive care 5980 84% S - AM 3100 53% (5000-970) 16% I are those with high mortality. (Tab.4) Tab. 2: RECOVERY AND SURGICAL INERVENT 2010–2014

INDICATORS/YEARS 2010 2011 2012 2013 2014 TOTAL (n-%) MALE/ A. Total hospitalized 7423 6023 5770 4835 5827 29906 FEMALE B. Surgical hospitalized 5421 4639 4516 4108 5033 23717 C. TRAUMA 2597 2272 2418 2354 2432 12073 ( 40.3% A.–51% B.) Fractures (head, neck, extremities, luxations) 172 98 87 935 1097 2389 (20%) Trauma within the skull 1563 739 766 803 737 4608 (38%) Trauma chest, abdomen, pelvis 752 381 118 392 213 1856 (15.3%) M 74% Vulnus (head, neck, torso, limbs) 110 53 57 90 121 431 (4%) Age 0–1 18 9 16 11 17 71 (0.6%) F 26% Age 1 –14 47 21 21 261 261 611 (5%) Age 15–65+ 2532 1241 991 2082 2154 9000 (74.5%) INCIDENCE ‰ (Trauma÷Emergency case) 61 ‰ 58.5 ‰ 73.8 ‰ 53 ‰ 62.8 ‰ 12073 61.8 ‰

Tab. 3: BASIC INDICATORS OF TRAUMA IN UHTMH

CASE The comparison of the data for the treatment % PATINETS YEARS MORTALITY % RECOVERY Mortality UTMH ICU of trauma at UTHMH tertiary hospitals of the ICU University Hospital Center (trauma of medium 2010 7423 2.1% 802 163 20.3% 2011 6023 2.5% 756 155 20.5% and heavy severity) shows that 40% of the 2012 5770 2.1% 719 123 17.1% cases were treated at our hospital and only 2013 4835 2.2% 619 110 17.7% 5.7–6% in the University Hospital Centre in 2014 5827 2 % 672 116 17.2% Tirana. Other hospitals treat minor trauma. Total AM 5975 2.2% 713 133 18.5% The data proves that UTHMH has its weight in

Tab. 4: Mortality UHTMH 2010–2014 the proper treatment of trauma (Tab. 6).

66 MCIF 3/2015 YEARS UHTMH UHC “Mother Teresa” DISTRICT HOSPITALS TOTAL CASES % CASES % CASES % CASES % 2010 4750 41.5 612 5.3 6090 53.1 11452 100 2011 4367 32.4 550 4.0 8557 63.0 13474 100 2012 3518 30.6 885 7.7 7076 61.0 11479 100 2013 4961 40.4 701 5.7 6617 53.8 12279 100 2014 4705 41.2 680 5.9 6025 52.8 11410 100 TOTAL 22301 37.1 3428 5.7 34365 57.0 60094 100

Tab. 6: TRAUMA TREATMENT IN UHT&MH, UHC "Mother Teresa“& DISTRICT HOSPITAL

nn The statistical data and the volume of work of health policy at the Ministry of Health, to Conclusions provide a full profile of UTHMH as tertiary set up a national program for the treatment nn Nowadays the “epidemic of trauma” is evi- hospital that treats trauma at national level. of trauma in the whole country. dent in Albania, its treatment in UTHMH nn Work trauma and car accidents occupy a nn Creating a national trauma registry and remains of primary importance. leading place in the epidemiological profile. computerization, currently lacking, needs nn Further modernization, personnel training to be looked at. n in UTHMH is and should have the attention

AUTHORS Colonel (R) Ph D Luan Nikollari Albanian Armed Forces, Epidemiologist, Chief of Statistical Service, University Hospital Trauma & Military Hospital in Tirana, Albania 1972– 1976 High Medical School, Pharmacy Technician; 1977– 1983 University of Tirana, Faculty of Medicine, Branch GP, Tirana; 1991– 1992 Specialization in Public Health, Epidemiology Branch, Public Health Institute, Tirana; 1995 Course on HIV / AIDS, “Instituto Superiore di Sanita” Rome, Italy. 1997 Course on Epidemiology, Military Medical Academy “GATA” Ankara, Turkey; 1998 Training at the Military Hospital “CELIO” and Study Center of Medical Research in Military Preventive Medicine, Rome, Italy. 1983– 1993 Chief of Medical Service Fantery Brigade in South Albania; 1993– 1998 Head of Service of Preventive Medicine and Health preparation, Department of Health, SHPFA, Ministry of Defence; 1999– 2000 University Central Military Hospital (SUQU), Head of the Department of epidemiology; 2000– 2006 Ministry of Defense, GSAAF, Director of Medical Service Albanian Armed Forces; 2006-2012 Director of Medical Military Institute at Central University Military Hospital. 2013 onwards: Chief of Statistical Service at University Hospital Trauma & Military Hospital in Tirana, Albania

Address for the authors: Spitali Ushtarak; Rruga “Lord Bajron” Laprakë; Tirana-ALBANIA; ++355 664010141 (Mobile); e-mail: [email protected] First and corresponding author

CO-AUTHOR Pharmacist E. Nikollari Chief of Pharmacy Service, University Hospital Trauma & Military Hospital in Tirana, Albania 2004–2009 Military Accademy of Modena and University of Modena and Reggio Emilia studies, Faculty of Pharmaceuti- cal Sciences-Italy, 2012 onwards: Chief of Pharmaceutical Service at University Hospital Trauma & Military Hospital in Tirana, Albania

A publicat ion of Beta Publishing 8,30 € I 11.00 US$ 3 / 2015

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MCIF 3/2015 67 COMEDS

43rd COMEDS Plenary Session in Berlin The Committee of the Chiefs of Military Medical Services in NATO (COMEDS) met the first week of June in Berlin for its 43RD plenary session. 81 participants attended representing 33 nations (22 NATO and 11 partners). In the follow-on of the Wales Summit, NATO works on the Readiness Action Plan (RAP) which is the biggest reinforcement of NATO’s collective defence since the end of the Cold War, the of the medical reserve support to NATO missions, food enhancement of the NATO Defence Planning Process (NDPP), defense and training. the Smart Defence (SD), the Connected Forces Initiative (CFI) A great step forward has been made on Lessons Learned as and the Framework Nation Concept (FNC). CFI and the future COMEDS wanted to increase participation and interconnec- RAP implementation will be the tool to secure well trained and tions and to improve the responsiveness of the system. To exercised soldiers and a highly professional NATO Forces in the achieve these goals COMEDS supported the Centre of excel- future. A point on all these priorities have been presented and lence for military medicine in Budapest that develops a NATO discussed in the plenary. Medical Information and Knowledge Management System with COMEDS, through all its working groups and panels, works cur- a key component of a modified LL process using Lessons rently on around 150 topics that cover both operational med- Learned Portal. ical support and capability development. The NATO operational France, Germany, United Kingdom and United States of Amer- medical support doctrine is depicted in 72 allied publications ica presented each an update of their commitments to the that are revised every three years. This should regularly raise Ebola crisis. A new Smart Defence project, called “Tier 2.96 questions on management of the committee. Therefore, this Smart Defence – Responsiveness to Biological Outbreak” has plenary had a session on governance supported by four syndi- been presented to the chiefs of military medical services. The cates (system of meetings, information sharing, evaluation and proposal’s aim is to increase efficiency and effectiveness of collective training). The findings will serve for further develop- existing bio-response capabilities and provide availability for ments. NATO or participating nations in this project. The proposal will Among all topics, several ones were particularly discussed dur- allow NATO and nations to better prepare for a bio threat. ing the meeting: Medical leadership, future medical support, COMEDS is sponsor. medical ethics, force health protection capability, lessons The next plenary meeting will be in NATO HQ, Brussels, 16–18 learned process, shortfall of medical personnel, enhancement November 2015. It will then be the last meeting of the French presidency and Canada will take over. In 2016 Ireland will be the host of the spring-plenary session. The wonderful and very interesting city of Dublin will be a great place for the international participants. Authors: Edouard Halbert, MD, MSc Col, FRA, Defence Health Service, COMEDS Liaison Officer Gérard Nedellec, MD, PhD LtGl, FRA, Defence Medical Service, COMEDS Chairman

68 MCIF 3/2015 BUSINESS MIRROR

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MCIF 3/2015 69 BUSINESS MIRROR

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70 MCIF 3/2015 UPCOMING EVENTS

9.–11.10.2015 Australasian Military Hobart, Tasmania, Medicine Association Conference 201 Australia www.amma.asn.au/amma2015

8.–14.11.2015 6th ICMM Course for Health Support in Saharan Environment Tozeur, Tunesia www.cimm-icmm.org

17.–18.11.2015 3rd International Conference on Disaster and Military Medicine 2015 Düsseldorf, Germany www.events-beta.com

23.–25.11.2015 MILITARY AND VETERAN’S HEALTH RESEARCH FORUM Quebec, Canada https://cimvhr.ca

1.–4.12.2015 AMSUS 2015 San Antonio, USA http://amsusmeetings.org

2.–4.12.2015 Medexcon 2015 Ankara, Turkey www.medexcon.net

7.–12.12.2015 Bioterrorism and Health Intelligence Sydney, Australia sphcm.med.unsw.edu.au/

15.–19.2.2016 3rd ICMM PAN-ASIA PACIFIC CONGRESS ON MILITARY MEDICINE Moscow, Russia www.cimm-icmm.org

16.–18.2.2016 HPSN World 2016 Tampa, Florida, USA www.hpsn.com

18.–21.4.2016 15th Defence Services Asia Exhibition & Conference Kuala Lumpur, Malaysia www.dsaexhibition.com

April 2016 AMOPS 2016 Philiadelphia, USA amops.org

23.-26.5.2016 4th ICMM Pan European Regional Congress on Military Medicine Paris, France www.cimm-icmm.org

6.-9.6.2016 COMEDS 2016 Dublin, Ireland www.coemed.org/comeds

16.–18.2.2016 World Congress on CBRNe Science & Tbilisi, www.cscm-congress.org/ Consequence Management (CSCM) Republic of Georgia cscm-2016

MCIF 3/2015 71 IMPRINT

IMPRINT MEDICAL CORPS INTERNATIONAL FORUM 3/2015

Publishers: Official journal of the Heike Lange // Heinz-Jürgen Witzke NATO Centre of Excellence for Military Medicine (MILMED COE) International Editorial Advisory Group: Chairman: Brigadier General (ret) Rob van der Meer, MD The standing member of AMSUS Members: Major General (ret) Paul Alexander, Australia Major General (ret) Yanling Zhang, China Advertising Sales Japan: Lieutenant General (ret) Prof Dr Gérard Nédellec, Ted Asoshina // Echo Japan Corporation France Grande Maison Room 303 Major General Dr Daniel Tjen, Indonesia 2-2 // Kudan-kita 1-chome Major General (ret) Dr Kitab bin Eid Al-Otaibi, Chiyoda-ku // Tokyo 102-0073 // Japan Tel.: +81 (3) 3263-5065 Saudi-Arabia E-mail: [email protected] Air Marshall DP Joshi, PVSM, AVSM, PHS, India Major General MC Dr Andreas Stettbacher, Layout: Switzerland publishDESIGN Hanns-Friedrich Beckmann Tel.: +49 (2243) 841927 Correspondents: E-mail: [email protected] Capt Ulrik Holmbjerg, MD, Denmark www.publish-design.de Maj Valdas Meskauskas, MD, Lithuania Translations: Col Mehmet Eryilmaz, MD, Turkey The Translator Group Col Zoltan Vekerdi, MD, Hungary Kernserstr. 17 Maj Anders Kildal, Norway CH-6060 Sarnen LtCol Sven Torp, Norway www.the-business-translator.com

Col Felix Tayo, MC, Phillippines Frank Sprachen + Technik GmbH Col Atul Kotwal, SM, India Tel.: +49 (228) 854469-0 LtCol Jean-Claude Nsinga Bungiena, MD, E-mail: [email protected] NATO Science and Technology Republic of the Congo www.frank-st.de Printing: Organization – Editor-in-Chief: pva, Druck und Medien-Dienstleistungen GmbH Rear Admiral uh MC (ret) Dr Christoph Büttner, Tel.: +49 (6341) 142-0 Human Factors and Medicine Germany E-Mail: [email protected] E-mail: [email protected] www.pva.de (HFM) Panel Publications Senior Editor: Subscription: MEDICAL CORPS INTERNATIONAL FORUM Colonel MC (ret) Dr Hans-Eberhard Bosse, Germany appears four times a year, at the end of each quarter. E-mail: [email protected] Free of charge worldwide to military doctors and aid services. Subscription price for other subscribers: single Managing Editor: issues cost € 8.30 plus postage € 1.80 inland, € 6.20 Colonel MC Dr Stefan Göbbels MSc, Germany Europe, € 14.00 worldwide. The annual Subscription price E-mail: [email protected] is € 36.00 (Germany), € 53.00 (Europe) and € 84.00 (Worldwide) including postage. A subscription continues until it is cancelled, unless it is ordered for a limited Publishing Director: period. The cancellation must be received by the publisher Gertraud Assél two months before the appearance of the next issue. E-mail: [email protected] Current advertising price list: 2015 Assistant: Karen Thelen Contact: E-mail: [email protected] E-mail: [email protected] www.mci-forum.com

Production Manager: Thorsten Menzel Published by: E-mail: [email protected] Beta Verlag & Marketinggesellschaft mbH Celsiusstr. 43 // 53125 Bonn // Germany Advertising Sales International: Tel.: +49 (228) 91937-10 Gertraud Assél Fax: +49 (228) 91937-23 Celsiusstr. 43 // 53125 Bonn // Germany E-mail: [email protected] Tel.: +49 (228) 91937-59 www.beta-publishing.com E-mail: [email protected] Managing Director: Read all abstracts of the HFM Heike Lange Advertising Sales China: panel on the MCIF-website Parker Xu // UnionBandy Ltd. Founded by Room 2204, Jin Feng Building Heinz-Jürgen Witzke Shang Bu Nan Road Shenzhen // 518031 P.R. China The opinions expressed in the articles are exclusively the www.mcif-forum.com Tel.: +86 (755) 83753881 // -83753877 personal views of the authors and do not necessarily E-mail: [email protected] reflect the views of the MCIF.

72 MCIF 3/2015 Supporting you, wherever the action is.

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