The Journal of High Threat and Austere Medicine

Background Aum Shinrikyo pioneered the first impactful domestic mass-application of a nerve-agent since its inception in warfare.  Approximately 10% of responders and 23% of hospital staff reported symptoms of secondary exposure, fuelling concerns about the United Kingdom response.  Secondary exposure risks in chemical incidents continues across developed countries in lesser circumstances.

Legislation and guidance for emergency responders in specialist situations further compounds complexity of responding in challenging environments.  The Human Rights Act alongside modern western medico-legal philosophy encourages everything possible to preserve life. Conversely, this must be balanced against the risks to rescuers.

Specialist units have been established ensuring pre-hospital responders are protected while delivering care.  In England and Wales, this is through Hazardous Area Response Teams (HART).

These teams deliver Advanced Life Support (ALS) in challenging environments. However, the extent to which Personal Protective Equipment (PPE) affects the ability to deliver clinical interventions is not truly tested alongside human factors.

Methods An electronic database search for articles was undertaken, using a PRISMA framework for reporting, individual articles were then assessed using Critical Appraisal Skills Program (CASP) checklists before common themes were extrapolated using mixed methods to analyse the impact of PPE on clinical skills and human factors.

Results 14 articles were found for full review, being a mix of systematic reviews (n=2), simulative studies (n=11) and a masters thesis (n=1). Data was heterogenous with articles measuring specific skills including intubation, cannulation and chest compression quality with others taking a qualitative approach to impedance of skills i.e. effects on dexterity. Major flaws were identified in most of the literature.

Conclusion Findings from this review reveal PPE delays and affects clinical care — impacting human factors and exacerbating the standard of care delivered failing below normal standards. This needs full assessment and further research to inform guidance for operatives in this environment.

Background UK medical teams who respond to chemical attacks and industrial accidents require higher levels of Personal Protective Equipment (PPE) to deliver care, including Advanced Life Support (ALS).  However, there is limited research exploring the impact of PPE on the ability of responders to provide cardio-pulmonary resuscitation (CPR) and there is no guidance on changes to algorithms in these high consequence environments.

Methods A standardised simulation was repeated across five groups: control (plain uniform), gas tight suit, powered respirator protective suit, level 3 and level 4 PPE. Time to compressions and pauses between CPR sets were measured with a Corpuls-3 defibrillator. Additionally, participant physiology, fatigue and human factors were measured using the Anaesthetists Non-Technical-Skills Framework and Likert scaled feedback forms. This allowed holistic assessment of the impact of PPE on ALS.

Results As the level of PPE increased, a downwards trend in ‘good compressions’ from the control group to Gas Tight Suits (GTS) (50% and 12% respectively) with a mean absolute difference in GTS comparison to control of 38% (95% CI 19.90 – 55.47], p<0.01). This aligned with a reduction in participants’ confidence in performance and survivability using Likert scales. Basic physiology was measured to make an assessment on increasing fatigue with increasing level of PPE being shown.

Discussion PPE delays care and affects the quality of resuscitation. ‘Good compressions’ deteriorate as the level of PPE increases, suggesting participants’ ability to deliver ALS in higher levels of PPE is impaired. As such, further guidance is required in these specialised circumstances.

The current conflict in Ukraine has illustrated the problems and complexities of large-scale modern warfare in a cold-weather environment. Military operations in environments in which external temperatures can drop below -20˚C are often plagued by difficulties in transportation and supply. These factors can result in medical materiel being exposed to external temperatures for prolonged periods of time. Here, we evaluate the chemical and physical stability of two commercially available formulations of propofol (generic propofol and Diprivan) to decide if they are suitable for use in under arctic conditions. It was hypothesised that the simple molecular structures of both generic propofol and Diprivan would make them immune to cold-mediated degradation. Single particle optical sensing, laser diffraction particle size analysis and pH determination were used to assess the stability of each formulation following a series of freeze-thaw cycles. It was found that both formulations remained physically stable throughout each freeze-thaw cycle, confirming the initial hypothesis by indicating that both formulations should remain stable and physiologically active in the ambient temperatures of the arctic and near arctic environments. Further research is needed to determine the chemical stability of these formulations and to evaluate the impact of the resulting physiological consequences.

This literature review describes the time-dependent effects of tourniquet application in trauma care. Tourniquet application is discussed from both clinical and pathophysiologic perspectives as a graduated spectrum of injury starting from the time of initial tourniquet application through to terminal cellular death. Research was conducted utilising existing case studies and reviews of combat application tourniquet use and outcomes. This review also offers a discussion on the application of this information and a suggested two hour protocol to be introduced to any working environment where extended combat application tourniquet use may be encountered.

Literature reflecting the UK civilian and military healthcare experience indicates the potential advantages of integrating the advanced practitioner (AP) role within contemporary Defence operations. The UK Defence Medical Services (DMS) has facilitated the training of a limited number of emergency medicine APs, although existing research does not delineate their operational responsibilities, particularly their contributions to deployed pre-hospital emergency care (PHEC). This paper offers insights into the experiences of four APs deployed to the British Army Training Unit Kenya (BATUK) during Exercise HARAKA SPEAR from February 2024 to March 2024. It highlights their potential utility for remote medevac operations within the UK DMS.

Introduction An increasing number of children are living in conflict zones. Indiscriminative war tactics, such as aerial attacks and shelling areas, are frequently observed. The Syrian Civil War is an example of such a conflict. Despite efforts to adapt to the changing demographics of patients seen in military and humanitarian hospitals, pediatric war casualties have higher mortality rates than adults. Knowledge of the epidemiology of injuries and injury patterns of pediatric casualties may help to improve the preparedness of deployed medical staff and, therefore, may help to save lives. However, so far there is a lack of data concerning pediatric war casualties in general, particularly in Syria.

Methods A systematic review and qualitative synthesis were conducted to investigate the epidemiology, mechanism of injury, and injury patterns of pediatric war casualties during the Syrian Civil War. A systematic search was conducted using the following  databases: PubMed, EMBASE, Web of Science, and Google Scholar. Quality assessment tools were used for the included studies.

Results Out of the 2294 initial search results, 39 studies were eligible for inclusion. In total of 14,833 patients were included in the analysis. Primary and secondary blast injuries (39%) were the most common mechanisms of injury in children. The head (22%), thorax (19%), and abdomen (20%) were the most commonly injured body regions.

Conclusion Despite the changing face of war, pediatric war casualties present a similar pattern of injury to adults in historical conflicts. Training and preparation of medical personnel and equipment are pivotal to optimise care for this vulnerable patient population.