Revue Internationale des Services de Santé des Forces Armées CIMM Vol 92/1 by Military Medicine

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ARMED FORCES MEDICAL SERVICES Revue Internationale des Services de Santé des Forces Armées

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Editor-in-Chief / Rédacteur en chef Maj. Gen. Prof. (ret.) M. MORILLON (MD) mmorillon@cimm-icmm.org

Gp. Capt. D. LAMB (United Kingdom / Royaume-Uni) Maj. Gen. (ret.) KHALID A. ABU-AZAMAH AL-SAEDI (MD) (Saudi Arabia / Arabie Saoudite)

Assistant Chief-Editor / Rédacteur en chef adj oint Maj. Gen. Prof. H. BOISSEAUX (MD) hboisseaux@cimm-icmm.org Secretary of the Editorial Board Secrétaire du Comité de rédaction Adjt. Maj. I. HOSTENS ihostens@cimm-icmm.org

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Revue Internationale des Services de Santé des Forces Armées

International Committee of Military Medicine Comité International de Médecine Militaire Intergovernmental organization in relation with the WHO (Agreement approved by the 5th World Health Assembly on May 21, 1952), the WMA, the WVA, the ICRC, the CISM and the OIE. Organisation intergouvernementale en relation avec l’OMS (Accord approuvé par la 5ème Assemblée Mondiale de la Santé du 21 mai 1952), l’AMM, l’AMV, le CICR, le CISM et l’OIE. Founder and Secretary General from 1921 to 1975/Fondateur et Secrétaire Général de 1921 à 1975: Maj. Gen. J. VONCKEN, MD (Belgium/Belgique). Honorary Secretary-General/Secrétaire Général d’Honneur: Dr. J. SANABRIA, MD (Belgium/Belgique).

Chairman of the General Assembly and the Committee / Président de l’Assemblée Générale et du Comité Lieutenant General Bipin PURI, VSM, PHS (India/Inde) Deputy Chairmen / Vice-Présidents Major General Terawan Agus PUTRANTO, Sp.RAD(K) RI, M.D. (Indonesia/Indonésie) Major General Andreas STETTBACHER (Switzerland/Suisse)

GENERAL SECRETARIAT/SECRETARIAT GENERAL Secretary-General/Secrétaire Général Maj. Gen. (ret.) R. VAN HOOF, M.D. Deputy Secretary-General/Secrétaire Général Adjoint Maj. Gen. P. NEIRINCKX, M.D. Assistant of the Secretary-General/Assistant du Secrétaire Général Brig. Gen. (ret.) Prof. L. KLEIN, M.D. Assistant of the Secretary-General/Assistant du Secrétaire Général Lt.-Col. M. E. PRESA GARCIA, M.D. Director of Communication and Marketing/Directeur Communication et Marketing Mr. P. ZABOURI Director of Finances/Directeur Financier Col. MMA (ret.) C. DEROUBAIX Legal Advisors of the Secretary-General/Conseillers juridiques du Secrétaire Général Col. Prof. (ret.) I. KHOLIKOV, Ph.D. Col. (ret.) J. CROUSE Office Manager Secretariat General/Chef de bureau du Secrétariat Général Capt. Pharm. L. PIERRE-VICTOR Executive Secretary/Secrétaire de Direction Adjt. Maj. I. HOSTENS

SCIENTIFIC COUNCIL/CONSEIL SCIENTIFIQUE

Chairman of the Scientific Council/Président du Conseil Scientifique Maj. Gen. Prof. (ret.) M. MORILLON, M.D. Deputy Chairman of the Scientific Council/Vice-Président du Conseil Scientifique Maj. Gen. Prof. H. BOISSEAUX, M.D. Chairman of the Reference Center for Education on International Humanitarian Law and Ethics/ Président du Centre de Référence pour la Formation au Droit International Humanitaire et à l’Éthique Lt.-Col. PD Dr. med. et. phil. D. WINKLER, M.D., Ph.D. (Switzerland/Suisse) Chairman of the Commission for Medico-Military Administration/Président de la Commission d’Administration Médico-Militaire Sen. Col. Prof. M. YU (China/Chine) Chairman of the Commission for Dentistry/Président de la Commission d’Odontologie Col. (Dent.) A. KOSARAJU, DMD, Msed, BS. (U.S.A./Etats-Unis) Chairman of the Commission for Pharmacy/Président de la Commission de Pharmacie Sen. Col. (Pharm.) A. KRAPPITZ (Germany/Allemagne) Chairman of the Commission for Veterinary Sciences/Président de la Commission des Sciences Vétérinaires Col. Dr. (Vet.) L. BUCHNER (Germany/Allemagne) Chairwoman (a.i.) of the Commission for Nurses & Paramedics/Présidente (a.i.) de la Commission des Infirmières & Paramédicaux Gp. Capt. Prof. D. LAMB (United Kingdom/Royaume-Uni) Medico Legal Advisor of the Chairman of the Scientific Council/Conseiller médico-juridique du Président du Conseil Scientifique Col. (ret.) J. CROUSE (South Africa/Afrique du Sud)

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Honorary Chairmen/Présidents d’Honneur Gen. M. BEN BOUMEHDI (Morocco) - Gen. A. LAIN GONZALEZ (Spain) - Maj. Gen. Ö. SARLAK (Turkey) - Gen. G. DESCH (Germany) - Maj. Gen. Z. LU (PR of China) - Gen. R. SCHLÖGEL (Austria) - Maj. Gen. T. SAHI (Finland) - Lt Gen. J.L. VAN RENSBURG (South Africa) - Dr. W. WINKENWERDER, Jr (USA) - Maj. Gen. A. BELEVITIN (Russian Federation) - Brig. Gen. (MD) M. K. CHEBBI(†) (Tunisia/Tunisie) - Lt. Gen. Dato’ (Dr) S. bin ABDULLAH (Malaysia/Malaisie) - Brig. Gen. (Dr) H. MA AGADA (Nigeria/Nigéria) - Maj. Gen. S. M. AL-MALIK (Saudi Arabia/Arabie Saoudite).

Revue Internationale des Services de Santé des Forces Armées

International Review of the Armed Forces Medical Services

P A Y S F O N D A T E U R S / F O U N D E R S TA T E S Belgique, Brésil, Espagne, Etats-Unis d’Amérique, France, Italie, Royaume-Uni, Suisse. Belgium, Brazil, France, Italy, Spain, Switzerland, United Kingdom, United States of America.

E T A T S M E M B R E S / M E M B E R S TA T E S Afghanistan/Afghanistan : Lieutenant General Prof. Abdul Razaq SIAWASH Afrique du Sud/South Africa : Lieutenant General (Dr.) A.P. SEDIBE Albanie/Albania : Brigadier General Bajram BEGAJ Algérie/Algeria : Médecin Général Abdelkader BENDJELLOUL Allemagne/ Germany : Lieutenant General Dr. Med. Ulrich BAUMGÄRTNER, M.D. Angola/Angola : Lieutenant General Dr. Alberto DE ALMEIDA, MD Arabie Saoudite/Saudi Arabia: Colonel (Pharm.) Ali Ahmed ALKINANI, MSc. Argentine/Argentina : Coronel Fernando Luis POSE Arménie/Armenia : Lieutenant Colonel Gayane HOVHANNISYAN Australie/Australia : Air Vice-Marshal Tracy SMART Autriche/Austria : Brigadier General Silvia-Carolina SPERANDIO, MD, PhD, MBA Azerbaidjan/Azerbaij an : Major General Natig ALIYEV Bahreïn/Bahrain : Brig. (Prof.) Khalid BIN ALI AL KHALIFA Bangladesh/Bangladesh : Major General (Dr) Fashiur RAHMAN Belg ique/Belgium : Médecin Général-major Geert LAIRE Bolivie/Bolivia : Gerente de Salud de COSSMIL Brésil/ Brazil : Brigadier General Médico Eduardo Serra NEGRA CAMERINI Bulgarie/Bulgaria: Brig. Gen. Prof. Dr. Ventsislav MUTAFCHIYSKI, MD, PhD, DSc FACS Burkina Faso/ Burkina Faso : Médecin Colonel-major Hamado KAFANDO Burundi/Burundi : Major Docteur Donatien IRAMBONA Cameroun/ Cameroon : Colonel Médecin Ambroise Emmanuel MAMA Canada/ Canada : Colonel Peter CLIFFORD Rép. Centrafricaine/ Central African Rep.: Médecin Colonel Eudes GBANGBA-NGAI Chili/ Chile : Contralmirante Boris SANCHEZ MANRIQUEZ Chine/ China : Major General Jingyuan CHEN Chypre/ Cyprus : Lieutenant Colonel Nicholaos MICHAELIDES, M.D. Rép. Dém. du Congo/Dem. Rep. of Congo: Médecin Général-Major Louis KAKUDJI ILUNGA Rép. Congo/Rep. Congo : Médecin Général de Brigade Pascal IBATA Corée/Korea : Brigadier General Woong SEOG Côte d’Ivoire/Cote d’Ivoire: Médecin Général de Brigade Prof. Dowlo N'Dri Athanase YAO Croatie/ Croatia : Colonel Velijko VUKIC, M.D. Cuba/ Cuba : Coronel Francisco MARTINEZ QUINTELA Danemark/Denmark : Brigadier General Sten HULGAARD Djibouti/Dj ibouti : Médecin Colonel Ahmed Hassan BOULALEH Rép. Dominicaine/Dominican Rep.: Coronel Med. Psi., FARD Pedro Arnald FERNANDEZ TEJADA Egypte/Egypt: Major General Magdy Amin MOBARAK El Salvador/El Salvador : Coronel de Infanteria DEM. Luis Oscar GALDAMEZ AMAYA Emirats Arabes Unis/ United Arab Emirates: Staff Brigadier Matar Saeed AL NEAIMI Espagne/Spain: General de División Médico José María ALONSO DE VEGA Estonie/ Estonia : Lieutenant Colonel Targo LUSTI Etats-Unis/ U.S.A. : Mr. Thomas McCAFFERY Finlande/Finland : Brigadier General Simo SIITONEN France/France : Médecin Général des armées Maryline GYGAX GENERO E.R.Y. de Macédoine/F.Y.R.O. Macedonia : Colonel Dusan STOJANOVIK Gabon/ Gabon : Médecin Général Professeur Jean Raymond NZENZE Ghana/ Ghana : Brigadier General Ernest CROSBY SAKA Grèce/ Greece : Major General Georgios TOLOUMIS, M.D. Guinée/ Guinea : Pharmacien Colonel Ibrahima Kalil TOURE Haïti/ Haiti : Docteur Paul BERNE Honduras/ Honduras : Coronel de Sanidad Irma Asucena BAQUEDANO CANALES Hongrie/Hungary : Brigadier Dr. István KOPSCÓ Inde/ India : Lieutenant General Bipin PURI, VSM, PHS Indonésie/ Indonesia : Major General (Dr.) Ben Yura RIMBA, MD, MHA, MARS Irak/ Iraq : Major General Fadhel Abd AL-HUSSAIN JABER, M.D. Iran/ Iran : Brigadier General Dr. Hasan ARAGHIZADEH Irlande/ Ireland : Colonel Gerald M. KERR Israël/ Israel : Brigadier General Tarif BADER, M.D. Italie/Italy : Major General Nicola Aldo SEBASTIANI Japon/Japan : Mr. Katsushi TAHARA

Jordanie/Jordan : Major General Dr. Saad Fayez JABER Koweït/Kuwait: Dr. Yousef Ahmed AL-NESEF Lettonie/Latvia : Lieutenant Colonel Janis MICANS Liban/Lebanon : General Georges YOUSSEF Libéria/Liberia : Dr. Josiah T. GEORGE Libye/Libya: Brigadier General Homdi OMAR ELBASIR Lituanie/Lithuania : Lieutenant Colonel Jolita SESARTIENĖ Luxembourg/Luxemburg: Médecin Lt.-Colonel Cyrille DUPONT Madagascar/Madagascar : Médecin Général de Brigade A. W. RAKOTOVAO Malaisie/Malaysia : Lieutenant General Dato’ (Dr.) Hj YA’AKOP BIN KOMING Mali/Mali : Médecin Colonel Major Boubacar DEMBELE Malte/Malta : Surg. Lt.-Colonel Dr. Giacinto BARTOLO, MD Maroc/Morocco : Médecin Général de Brigade Abdelhamid HDA Mauritanie/Mauritania: Médecin Général de Brigade Teyeb Mohamed Mahmoud EBOU Mexique/Mexico : Contralmirante SSN. MC. Derm. Luis Alberto BONILLA ARCAUTE Namibie/Namibia : Colonel Bernadette Hilya IITA Nicaragua/Nicaragua : Coronel Médico Dr. Marco Antonio SALAS CRUZ Nigéria/Nigeria : Surgeon Rear Admiral Lawan Modu ADAMS Norvège/Norway : Major General Jon Gerhard REICHELT Nouvelle-Zélande/New Zealand : Brigadier General Andrew GRAY Oman/ Oman : Brigadier (Dr) Ali Nasser Juma AL MASKARI Ordre de Malte/Sovereign Order of Malta: Chevalier Dr. Frans De WEER, MD, FACS Ouganda/ Uganda : Brigadier General Dr. Ambrose Keith MUSINGUZI Pakistan/Pakistan : Lieutenant General Zahid HAMID Palestine/Palestine : Dr. Maysoun EL BANNA Paraguay/Paraguay : Coronel de Sanidad med. Dr. Jacinto Rafael NOGUERA Pays-Bas/ The Netherlands : Commandeur (OF-6- Navy) Remco W. BLOM Pérou/Peru : Coronel EP San MED Jaime AVALOS DIANDERAS Philippines/Philippines : Colonel Felix T. TERENCIO MC (GSC) Pologne/Poland : Colonel Slawomir CHMIEL, M.D. Portugal/Portugal: Commodore José Manuel Jesus SILVA Qatar/ Qatar : Brigadier General (Navy) Staff Naser Mohammed AL-KAABI Roumanie/Romania : Brigadier General Medic Dr. Ionel Paul OPREA Royaume-Uni/ United Kingdom: Surgeon General of the Armed Forces Medical Services Fédération de Russie/Russian Federation : Dr. Dmitry TRISKIN Saint-Siège/Holy See : Monsieur l’Abbé Robrecht BOONE Sénégal/Senegal : Médecin Colonel Ibrahima DIOUF Serbie/Serbia : Colonel Prof. Miroslav VUKOSAVLJEVIĆ, M.D., PhD Singapour/Singapore : Rear Admiral (Dr.) Kong Choong TANG Slovaquie/Slovakia : Colonel Vladimir LENGVARSKY, M.D., MPh Slovénie/Slovenia : Colonel Dr. Andrej LIKAR, D.D. Soudan/Sudan : Lieutenant General Khatir Mohamed TOBAY EISA Sri Lanka/Sri Lanka : Air Vice Marshal (Dr.) Lalith Rukman JAYAWEERA Suède/Sweden : Colonel Claes IVGREN Suisse/Switzerland: Divisionnaire Andreas STETTBACHER Syrie/Syria : Director General of the Armed Forces Medical Services Tchad/ Chad : Médecin Général de Division Beure MBAINDONADJI Rép. Tchèque/ Czech Rep. : Brigadier General (Dr.) Zoltan BUBENIK, M.D. Thaïlande/ Thailand: Lieutenant General Channarong NAKASAWASDI, M.D. Togo/ Togo: Médecin Colonel Wiyao Kpao ADOM Tunisie/ Tunisia : Médecin Général de brigade Mustapha FERJANI Turquie/ Turkey : Brigadier General Prof. Ufuk DEMIRKILIC, M.D. Union des Comores/ Union of the Comoros: Médecin Commandant A. NAOUFAL BOINA Uruguay/ Uruguay : General Alejandro SALABERRY COCCARO Vénézuela/ Venezuela : General de División Médico Pedro Jesus SERRANO DUQUE Viêt Nam/ Vietman : Senior Colonel Xuan Nguyen KIEN Yémen/ Yemen : Brigadier Dr. Mohammed A. AL-MEKHLAFI Zambie/Zambia : Brigadier General (Dr.) Frank H. SINYANGWE

PAY S O B S E RVAT E U R S / O B S E R VE R S Bielorussie/ Belarus - Cambodge/ Cambodia - Kenya/ Kenya - Myanmar/ Myanmar - Rwanda/ Rwanda

M EMBRES

D ’ HO NNEUR / H ON ORA R Y

M EMBERS

Maj. Gen. Dr E. DELIYANNAKIS (Grèce) - Col. Dr E. DASKALAKIS (Grèce) - Lt.-Col. Méd. L. VAZEOS (Grèce) - Maj. Gen. Dr K. KOSKENVUO (Finlande) - Maj. Gen. Dr S.M. AL-SHAMMA (Irak) - Méd. Col. S. NEJMI (Maroc) - Gen. Dr A. DOMINGO GUTIÉRREZ (Espagne) - Col. Dr Prof. K. SAVASAN (Turquie) - Col. Dr F. MEISSNER (Allemagne) Sen. Col. LI Chaolin (R.P. Chine) - Méd. Col. H. HARBICH (Autriche) - Col. Dr Ari PEITSO (Finlande) - Maj. Gen. A.J. LANDMAN (Afrique du Sud) - Col. Vet. R. SHORT (Afrique du Sud). Médecin Colonel HAOUALA (Tunisie) - Médecin Colonel MACHGHOUL (Tunisie) - Brig. Gen. Dato’ (Dr) Mohd ZIN BIDIN (Malaisie) - Surg. Cdre AB AFOLAYAN (Nigeria) - Maj. Gen. Khalid ALSAEDI (Arabie Saoudite) - Maj. Gen. Terawan Agus PUTRANTO (Indonésie) - Air Commodore Rajesh VAIDYA (India).

Revue Internationale des Services de Santé des Forces Armées

International Review of the Armed Forces Medical Services

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CONTENTS Sommaire

Continuing Medical Relief Operations in a Military Medical Facility Compromised by a Flood Disaster: Lessons of Kashmir Floods 2014. By L. NS and P. SK. India.

ORIGINAL ARTICLES / ARTICLES ORIGINAUX

Major General Andreas STETTBACHER. Director General of the 43rd ICMM World Congress on Military Medicine.

43rd ICMM World Congress on Military Medicine. Welcome to Basel.

Particularités des lésions thoraciques dans un hôpital de maintien de la paix : cas de l’hôpital niveau 2 du Togo déployé à KIDAL (MALI). Par D. LAMBONI, H.D. SAMA, K. ASSOGBA, A. AMAVI, K. AKLOA, S. ASSENOUWE, G. AKALA, Y. AKPOTO, M. AKPANAHE, B. KOUTORA, F. GNANDI-PIOU, K.E. MOSSI et A. ABALO. Togo.

43rd ICMM World Congress on Military Medicine. Swiss Armed Forces Medical Services.

From Organ Support to Organism Support: Extra Corporeal Membrane Oxygenation in Military Combat Trauma. By V. SRIVASTAVA, NS. LAMBA, M. NAKRA and A. SHANKAR. India.

H1N1 Outbreak Onboard A Warship: Ethics of Vaccination, To Give or Not To. 70 Mass Casualty Management during UN Mission By A. GUPTA, N. GOYAL, S. RAY, N. CHAWLA and P. CHAUHAN. India. in Mali: An Evaluation. By X. YU, X. CAO, S. HAN and G. BI. P.R. of China.

Fluid Resuscitation in Trauma-Looking Beyond the ATLS Recommendations. By R. SETLUR. India.

The Rehabilitation and Treatment of scar by Laser Technology. By H. CAI, Y.X. WANG, Z.J. XING, P. SUN, Q.Y. XU, A.Q. JU and W. LIU. P.R. China.

Profil épidémiologique et clinique des dermatoses chez les réfugiés maliens de Goudebou au Burkina Faso. 81 Par Y. KARABINTA, I. KONATÉ, L. CISSÉ, O. SYLLA, M. GASSAMA, 2008-2018, After the Explosion of an A. DICKO, K. COULIBALY, NANCY WALTERS, S. DAO, O. FAYE et Ammunition Stockpile... S. KEITA. Mali. By L. NIKOLLARI, A. BEJLERI, D. VASHA, M. MJEDA and E. NIKOLLARI. Albania.

Photo on the cover: Training in the Swiss Armed Forces Medical Service (SAFMS).

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Views and opinions expressed in this Review are those of the authors and imply no relationship to author’s official authorities policy, present or future.

International Review of the Armed Forces Medical Services

Les idées et opinions exprimées dans cette Revue sont celles des auteurs et ne reflètent pas nécessairement la politique officielle, présente ou future des autorités dont relèvent les auteurs.

Revue Internationale des Services de Santé des Forces Armées

43RD ICMM W ORLD CONGRESS

M ILITA RY MEDICINE

BASEL, SW ITZERLA ND MAY 19-24, 2019

Major General Andreas STETTBACHER, MD, Surg FMH CHE, began his military career in 1982 as a soldier of the medical corps where he started his medical school training at the University of Bern, Switzerland. During the last three years of his studies, he was at the Department of Legal Medicine of the University of Bern, where he wrote his master’s thesis on the research of ethanol depletion in low concentrations in humans. Having served as a conscript officer, he attained the rank of medical corps captain by the time he graduated from medical school, serving as a battalion surgeon in infantry and artillery battalions. During that time, Major General STETTBACHER specialised in general surgery, served in several civilian hospitals in urology, visceral surgery and orthopaedics, anaesthesia and intensive care, and finally in cardiothoracic and vascular surgery at the University Hospital in Bern. In 1997, he left for South Africa, where he worked as a trauma surgeon at Groote Schuur Hospital in Cape Town, even becoming the head of surgery and chief of medical services of two major regional hospitals in Cape Town. During that time, he served as a reserve regimental surgeon in a rapid deployment infantry regiment and held the positions of chief medical officer of the OSCE in Bosnia and chief medical officer of Swisscoy in Kosovo. After his return to Switzerland in 2001, Major General STETTBACHER held several key administrative management positions within the Medical Services Directorate and in the former Armed Forces Joint Staff of the Department of Defence, Civil Protection and Sport. In his function he's been deployed several times abroad for his expertise in emergency services, including Bam, Iran after the 2003 devastating earthquake which saw a high toll of death and injuries, displacing over 75,000 people. Since 2005 he served as a colonel of the Military Strategic Staff and held the position of deputy surgeon general. Then, the Federal Council appointed Major General Stettbacher as Surgeon General of the Swiss Armed Forces and Commissioner of the Federal Council for the Coordinated Medical Services (CMS) from the 1st of January 2009. His responsabilities include heading the Medical Services of the Armed Forces (Fig. 1), which include the Medical Directorate, the Federal Centre of Competence for Military and Disaster Medicine, the Armed Forces Pharmacy and the Veterinarian Service. He has received several distinctions for excellence in military skills and service medals for his participation in several military operations in Switzerland and abroad. Major General STETTBACHER is member of the Swiss Medical Society, the Swiss Surgical Society and the International Society of Surgery.

International Review of the Armed Forces Medical Services

Fig. 1: Insignia of the Swiss Armed Forces Medical Services.

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43RD ICMM W ORLD CONGRESS

M ILITA RY MEDICINE

BASEL, SW ITZERLA ND MAY 19-24, 2019

Fig. 2: Basel's Rhine panorama1.

SWITZERLAND AND THE ICMM Major General Jules VONCKEN, MD (Belgium) and his colleague Captain William S. BAINBRIDGE (US Navy) observed the lack of coordination between the military health services of different parties and the inadequacy of the cares given to victims, the sick and prisoners during the First World War. In response to this, they decided to launch a plan to develop an international committee of military medicine. Switzerland was one of the eight founding countries at the first congress in 1921 in Brussels, where the International Committee of Military Medicine (ICMM) was constituted. The ICMM is an international and intergovernmental organization with currently 117 member countries. THE FASCINATION OF BASEL 1, 2 Basel is a city in northwest of Switzerland along the river Rhine (Fig. 2), bordering France and Germany, making it possible to visit three countries at the same time. It is the third largest Swiss city after Zürich and Geneva with about 200,000 residents3 . Today, the city of Basel is counted among the cities with the highest standards of living in the world4 . Basel has a Mediterranean climate and has around three-hundred days of sunshine per year (Fig. 3) . If the weather is good; the people enjoy outdoors (Fig. 4). The three "most beautiful days" for the people of Basel occur during the famous carnival. During this carnival, the people discover creative masks, colourful costumes and wonderful lanterns (Fig. 5). Basel is proud home to a top football club and of course, the king of tennis Roger Federer, who grew up and started his tennis career in the area.

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Fig. 3: Merian Gardens Basel1.

The people of Basel’s “love of art” is manifested everywhere: It is not by chance that there are forty museums within this small area. The city is known for many internationally renowned art centers, hosting the first collection of art accessible to the public in Europe (1661) and the largest museum of art in Switzerland. The “Fondation Beyeler” Museum in Riehen (designed by Renzo Piano 1997) holds a collection of 200 works of classic modernism which reflect the views of Hildy and Ernst Beyeler on 20th-century art and highlight works typical to the period of Claude Monet, Paul Cézanne, Vincent van

International InternationalReview Reviewofofthe theArmed ArmedForces ForcesMedical MedicalServices Service

1. ̈ Fig. 4: Between friends at the Rhyschanzli

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Gogh, Pablo Picasso, Andy Warhol, Roy Lichtenstein, Francis Bacon, Alberto Giacometti and many others. The Museum Tinguely (an interesting building designed by Mario Botta in 1996) is one of Basel’s top art museums and he has world’s largest collection of art by Jean Tinguely, famous for his moving mechanical sculptures (Fig. 6). In Basel you can embark on a journey into the past spanning many eras. There can be few other cityscapes where buildings dating back as far as the 15th century engage so harmoniously and vibrantly with the contemporary creations of internationally distinguished architects. Basel is host of an array of buildings by internationally renowned architects5 and hosts the architectural practice of Herzog & de Meuron known as for the Messe Basel New Hall (venue of the ICMM World Congress 2019), the MOH Meret Oppe nheim Hochhaus in Basel, the Vitra Haus (Vitra Campus) in Weil am Rhein, the Tate Modern in London, the Bird’s Nest in Beijing (Olympia stadium) and the Elbe Philharmonic Hall in Hamburg. The red sandstone Minster Catheral (Fig. 7) is one of the foremost late-Romanesque/early-Gothic buildings in the Upper Rhine. Inside a memorial to Erasmus can be observed. The City Hall from the 16th century is located on the Market Square (Fig. 9) and is decorated with fine murals on the outer walls of the inner court. Basel’s Market Hall was built in 1929 and was used as a market until 2004. Currently the hall has being renovated to almost its original purpose, with food stalls offering delicious products. The building looks a little run down, but inside, you can marvel at the massive dome with a glass covered oculus in the centre, while enjoying delicious food. The city on the Rhine moreover boasts fabulous flea markets where there are still real treasures to be found. The region is no longer just an insider’s tip for gourmets and to enjoy over twenty restaurants that have won GaultMillau or Michelin awards. Let Peter Knogl, «Chef of the year 2015», indulge your culinary dreams at the Cheval Blanc, a restaurant with three Michelin stars. The Roche Tower with a height of 178 meters is Switzerland’s tallest building. The building was funded by Roche, the pharmaceutical giant with its headquarters in Switzerland. Home to another pharmaceutical giant, the Novartis Campus is an impressive, if not slightly overwhelming blend of

Fig. 5: Carnival of Basel1.

Fig. 6: At Museum Tinguely 1.

Fig. 7: Minster of Basel1.

Fig. 8: Tinguely's Fountain1.

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curving metal and reflective glass designed by Italian architect Vittorio Magnago Lampugnani. The Goetheanum stands 10 kilometres outside of Basel in the nearby Dornach. It was built for the Anthroposophical Society, a group whose aim is “to nurture the life of the soul”. There is inside its bizarre shape enough space for two performance halls, a library and ample space for the Society members to go about their daily work. The University of Basel is Switzerland’s oldest university, which was founded on April 4th, 1460. Besides lending the city an aura of innovation and thirst for knowledge, it also attracts many young people to Basel, who make life here more colourful than elsewhere. Famous personalities like Erasmus, Paracelsus, Daniel Bernoulli, Leonhard Euler, Jakob Burckhardt, Friedrich Nietzsche, Tadeusz Reichstein, Karl Jaspers, Carl Gustav Jung and Karl Barth worked there. Basel is one of the few cities with two internationally renowned orchestras. The symphony orchestra and the chamber music orchestra play regularly at the world’s greatest concert halls. Switzerland’s biggest theatre offers drama, opera, dance and is known for its outstanding productions and broad repertoire. The famous Tinguely fountain in front of the theatre offers visitors an idea of what to expect inside (Fig. 8).

Fig. 9: City Hall and Market Square of Basel1.

Basel’s population is very attached to its internationally famous Zoo Basel which is a popular excursion destination. This zoo is entirely surrounded by the city of Basel. The zoo is the oldest in Switzerland, providing visitors with an impressive insight into flora and fauna from around the world. The first worldwide Indian rhinoceros6 birth, the greater flamingo hatch7 in a zoo and other achievements, led Forbes Travel to rank Zoo Basel as one of the fifteen best zoos in the world in 20088 . Thanks to its location, bordering with France and Germany, to the established multinational companies and trade fairs held here, there is always a cosmopolitan air in the streets and passageways of Basel. It is therefore no wonder that the city’s inhabitants are considered to be particularly open-minded. The annual Federal Swiss trade fair takes place in Basel on the right bank of the Rhine since 1917. Other important trade shows include, Baselworld (watch and jewellery industry), Art Basel, Swissbau and Igeho (the international exhibition for hotels, catering, take-away and care). Not to mention, the Swiss chemical industry operates largely from Basel and many famous pharmaceutical companie such Novartis, Syngenta, Ciba, Hoffman- La Roche, Clariant, Actelion, are headquartered there. WHAT YOU SHOULD KNOW ABOUT SWITZERLAND9,

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Switzerland is a federal republic in the heart of Europe. The Swiss Confederation is situated in central Europe and is a landlocked country bordered by Italy, France, Germany, Austria and Liechtenstein (Fig. 10) 11. The total area consists of 41,285 km2 and a great part of the territory consists of the Alps. Forty-eight of Switzerland’s mountains are over 4,000 meters above sea-level12 . Monte Rosa at 4,634 m.a.s.l. is the highest Swiss mountain, although the Matterhorn at 4,478 m.a.s.l. is the most famous13 (Fig. 11). Zürich Airport is Switzerland’s largest international flight gateway; the other international airports are Geneva Airport and EuroAirport Basel-Mulhouse-Freiburg, located in France. Zürich and Geneva are global cities and economic centres of Switzerland. Switzerland is one of the most developed countries, with the highest nominal wealth per adult and the second-highest per capita gross domestic product according to the International Monetary Fund14, 15. Switzerland is ranked one of the top countries in the world in several facets of national performance, for example; solidarity, civil liberties, political transparency, human rights, quality of life, economic effectiveness, and human development. In addition, freedom of the press and the right to free expression is guaranteed in the federal constitution of Switzerland. Switzerland is part of the Schengen Area (26 European states) 16 and is a founding member of the European Free Trade Association (EFTA). Switzerland, which is also referred to as the Swiss Confederation, has been a federal state since 1848. The city of Bern is the capital and the seat of the federal authorities (Fig. 12). In 1815 the Congress of Vienna fully recognized Swiss independence and the European powers agreed to permanently acknowledge the policy of Swiss neutrality 17. Direct democracy and federalism are symbols of the Swiss political system. The Federal Constitution defines the Confederation’s tasks and responsibilities. These include Switzerland’s relations with the outside world, defence, the national road network, and nuclear energy. Switzerland’s Parliament, the Federal Assembly, is made up of the National Council and the Council of States. The government comprises of seven federal councillors and the Federal Supreme Court, which is responsible for national jurisprudence. The state power is shared between the federal government, the cantons and Fig. 10: Location of Switzerland (green) in Europe the communes. The separation of powers prevents a concentration of 2.

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power by an individual person or institution, and helps to stop any abuse of power. Power is divided between the three branches of state, the legislative, the executive and the judiciary. No single person can belong to more than one of the three branches of state at the same time. Federalism makes it possible for Switzerland to exist as one entity – in spite of four linguistic cultures and varying regional characteristics. The Confederation is made up of 26 cantons, which are also known as “states”. Each canton has its own parliament, government, courts and constitution. The cantonal constitutions may not contradict the Federal Constitution. The cantons implement the requirements of the Confederation, but structure their activities in accordance with their particular needs. They have a broad scope in deciding how to meet their responsibilities, for example in the areas of education and healthcare, cultural affairs and police matters. The 26 cantons are divided into communes. Each canton determines for itself the division of responsibilities between the canton and the communes. The responsibilities of the communes include local planning, running the schools, social welfare and the fire service. In Switzerland, around 5.3 million men and women can vote in federal elections. Swiss voters elect the Parliament (the legislature). This makes the electorate Switzerland’s supreme political body. Anyone who is eligible to Fig. 11: Swiss Mountains, the Matterhorn . vote is not only entitled to vote in the elections to Parliament, but can also stand as a candidate in the elections. The National Council represents the entire population, while the Council of States represents the 26 cantons. Federal elections are held every four years. The Parliament elects the members of various bodies: the executive (Federal Council and Federal Chancellor), the judiciary (Federal Supreme Court) and the Attorney General of Switzerland. 4

There are approximately 8.4 million people living in Switzerland, 25 percent of whom are foreign nationals. More than half of the inhabitants who do not have a Swiss passport, were either born in Switzerland or have been living there for at least ten years. The majority of foreign nationals come from EU or EFTA countries, predominantly from Italy (15%), Germany (14%) and Portugal (13%). 15 percent come from non-European states. Switzerland is a multilingual country. There are four national languages: German, French, Italian and Romansh. 63 percent of the population primarily speak Swiss-German, 23 percent French, 8 percent Italian and 0.5 percent Romansh, English, Portuguese, Albanian (3 to 5 percent of the population), and various other languages are also spoken in Switzerland. Many of the Swiss population state that they have two main languages in their households. As for religion, Christians make up 70 percent of people living in Switzerland. Catholics are the majority in 14 cantons; Protestants are the majority in 3. In the remaining cantons, there is no clear majority. Regardless of whether they are Christian, Muslim or Jewish, religion does not play a central role in the daily lives of most people. 23 percent of people are not members of any religion – this number has been on the rise for several years. 25.1 percent of the population are foreigners living in Switzerland and 38 percent of Swiss citizens have a migration background16. What do Swiss people, foreign nationals, new born babies in Switzerland and everybody staying in Switzerland for more than 90 days have in common? They all have the right to a basic health insurance in Switzerland. Every insured person pays a monthly premium to their choosen insurance company, this amount varies from insurer to insurer and from canton to canton. Although the costs of the system is among the highest, it compares well with other European countries in terms of health the citizens/benefits are highly satisfied with the Swiss health care system 18 . Education in Switzerland is very diverse because the constitution delegates the authority for the school system to the cantons. There are both public and private schools, including many private international schools. There are twelve universities in the country, ten of which are organized at cantonal level and usually offer a spectrum of non-technical topics. The first university in Switzerland was founded in 1460 in Basel (with a faculty of medicine) and has a tradition of chemical and medical research. The two institutes supported by the federal government are the Swiss Federal Institute of Technology Zurich (ETHZ) in Zürich, founded in 1855 and the "École Polytechnique Fédérale de Lausanne" (EPFL) in Lausanne, founded in 1969. In addition, there are various Universities of Applied Sciences19, 20 . Geneva and the nearby French department of Ain co-host the world’s largest laboratory, the European Organisation for Nuclear Research (CERN), dedicated to particle physics research. Another important research centre is the Paul Scherrer Institute in Zurich. The Switzerland Space Agency, the Swiss Space Office (SSO), has been involved in various space technologies and programs. Many Nobel Prize laureates have been Swiss scientists. They include the world-famous physicist Albert Einstein, who developed his special relativity theory while working in Bern. More recently Vladimir Prelog, Heinrich Rohrer, Richard Ernst, Edmond Fischer, Rolf Zinkernagel and Kurt Wüthrich received Nobel Prizes in science. In total, 113 Nobel Prize winners in all fields stand in relation to Switzerland and the Nobel Peace Prize has been awarded nine times to organizations residing in the country9 . Swiss culture is considered diverse, reflecting in the variety of traditional customs. Regional cultures are often influenced by the neighbouring countries, where people speak the same languages and share traditions. The typical gastronomy of Switzerland is multifaceted. You find the most popular dishes such as “Fondue”, “Raclette” or “Rösti” throughout

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the country; on top of that each region developed its own cuisine according to the differences of landscape, climate and languages. Traditional Swiss cuisine uses ingredients similar to the surrounding countries, as well as common foodstuff like cheeses, such as Gruyère or Emmental, and chocolate (Lindt & Sprüngli, Frey, Cailler, Milka or Toblerone). Many international institutions have their seats in Switzerland; in addition, Switzerland was a founding member and home to the League of Nations. Geneva is the birthplace of the Red Cross, founded in 1863 by Henry Dunant, and of the Red Crescent, Movement as well as the Geneva Conventions21. Since 2006, Geneva hosts the United Nations Human Rights Council. Apart from the United Nations headquarters, the Swiss Confederation is host to many UN agencies, such as the World Health Organization (WHO), the International Labour Organization (ILO), the International Telecommunication Union (ITU), the Universal Postal Union (UPU), the United Nations High Commissioner for Refugees (UNHCR) and about 200 other international organizations, including the World Trade Organization (WTO) and the World Intellectual Property Organization (WIPO). Furthermore, many sport federations and organizations are located throughout the country, such as the International Basketball Federation (FIBA) in Geneva, the International Ski Federation (FIS) in Bern, the Union of European Football Associations (UEFA) in Nyon, the International Federation of Association Football (FIFA) and the International Ice Hockey Federation (IIHF) both in Zürich, the International Cycling Union (UCI) in Aigle, and the International Olympic Committee (IOC) in Lausanne9 . Switzerland is home to many notable contributors to literature, art, architecture, music and sciences. Annually, several important cultural performances are held like the Paléo Festival in Nyon, the Lucerne Festival, the Montreux Jazz Festival, the Locarno International Film Festival, the Art Basel and many others22 . The most prominently watched sports in Switzerland are football, ice hockey, alpin skiing, Swiss wrestling called “Schwingen” and tennis. The largest Swiss lake, Lake Léman, is home of the sailing team Alinghi that was the first European team to win the America’s Cup in 2003 and which successfully defended the title again in 2007. Tennis has become an increasingly popular sport, and Swiss players such as Martina Hingis and Roger Federer have won multiple Grand Slams23 . Switzerland is ranked as having one of the most powerful economies in the world and is home to numerous large international enterprises. The largest Swiss companies by revenue are Glencore, Gunvor, Nestlé, Novartis, Hoffmann-La Roche, ABB, Mercuria Energy Group and Adecco24 . Also notable are: UBS AG, Zurich Financial Services, Credit Suisse, Barry Callebaut, Swiss Re, Tetra Pak and The Swatch Group. Switzerland’s most important economic area is manufacturing, which consists largely of the production of specialty chemicals, health and pharmaceutical goods, scientific and precision measuring instruments and musical instruments. The largest exported goods are chemicals (34% of exported goods), machines/electronics (20.9%), and precision instruments/watches (16.9%)25. Fig. 12: Federal Palace in Bern.

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43RD ICMM W ORLD CONGRESS

M ILITA RY MEDICINE

BASEL, SW ITZERLA ND MAY 19-24, 2019

Fig. 15: Training in the Armed Forces Medical Service.

THE SWISS ARMED FORCES The Armed Forces of neutral Switzerland are set up as a conscript system. The Swiss Armed Forces, which include the Land Forces and the Air Force, are composed mostly of conscripts: male citizens aged 19 to 34, and female volunteers. Professional soldiers constitute about 5% of military personnel. Swiss citizens are prohibited from serving in foreign armed forces, with the exception of the Pontifical Swiss Guard or in the case of dual citizenships if the individual is a resident of his other home country. Due to Switzerland’s status as a neutral nation, the Armed Forces do not take part in conflicts in other countries, but are active in international peacekeeping and humanitarian aid missions, e.g. Kosovo 1999-2020 (KFOR, Swisscoy), Namibia 1989-1990 (UNTAG), Western Sahara 1991-1994 (MINURSO), Afghanistan 2003-2008 (ISAF), Iran, Bam eart hquake in 2003, Sumatra, Tsunami in 2005 (N HCR). Switzerland participates in the NATO Partnership for Peace (PfP) programme. Annually, approximately 20,000 recruits undergo basic military training for 18 weeks. With the Armed Forces Development Programme, which is currently being implemented, the Parliament decided to reduce the Armed Forces' size. The number of available troops will decrease from 140,000 to 100,000, with 35,000 rapidly deployable soldiers that can be mobilised within 24 hours and ready for mission within a few days. The Swiss conscript system stipulates that soldiers are to keep their military-issued equipment, including all personal weapons, at home. Some organisations and political parties find this practice controversial; however, mainstream Swiss opinion supports this system. Conscript soldiers who serve in the Swiss Armed Forces offer great potential to the military, because they are able to apply their civilian work expertise in their military work. Compulsory military service ensures a balanced recruitment that drafts all male Swiss citizens. Women serve voluntarily. The Swiss recruitment centres are shown in Figure 13. About 1% of all soldiers are female. They serve in all military functions. Men usually receive conscription orders for military training at the age of 18. About two thirds of young Swiss men are found fit for service, and for those found unfit, various forms of alternative service exist. Annually, approximately

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Fig. 13: Swiss Recruitment Centres.

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20,000 individuals are instructed in recruit schools for 18 weeks. The most recent reform follows previous ones: forces strength was reduced from 800,000 during the Cold War to 400,000 in the nineties and 200,000 at the beginning of the 21st century. SWISS ARMED FORCES MEDICAL SERVICE (SAFMS) The SAFMS is a specialised cross-sectional service for the entire Armed Forces, for the Federal Administration and for other civilian beneficiaries. The SAFMS is part of the Armed Forces Staff; the position of the SAFMS within the Swiss Armed Forces is shown in Figure 14. The SAFMS pursues the following basic missions: • The core mission of the SAFMS is to provide medical support. It is, therefore, responsible for the health, operational ability and the readiness of the troops, in both war and peacetime and under CBRN conditions. It is the aim of the SAFMS to preserve or restore soldiers’ combat capability and morale in all circumstances. Hospital medical support is provided in close collaboration with civilian health care. Rapid recovery and rehabilitation – ensured in close cooperation with military health insurance, which is responsible for case management – is crucial for operational readiness. • The Surgeon General is responsible for the Coordinated Medical Services (CMS). This is a permanent national network that plans and coordinates all available medical resources on a federal level (civilian-military cooperation) in the event of war or in disaster and crisis response situations. Various possible incidents could cause the public health care system to fail and would disrupt daily life. The CMS ensures that such situations can be resolved efficiently. The Surgeon General officially represents the Swiss Federal Council in his civilian role within the CMS, taking on the role of Commissioner. • Regardless of the given circumstances, the cantons are at all times responsible for the civilian health care system and its management through cantonal regulations. The Confederation and the cantons bear joint responsibility for the management of disaster and emergency situations with a high number of patients (e.g. pandemics, earthquakes, armed conflicts). The SAFMS is the only resource on federal level that is ready at all times to operate as a partner of the CMS. • On a federal level, the SAFMS is the only substantial reserve in place for handling medical emergencies such as large-scale disasters and other major events as mentioned above. The other available resources are all at the disposal of the cantons or communes and are geared towards daily use. The national coordination and management of these resources is done at the respective government levels that are responsible for their deployment planning. The overall coordination by the CMS is impartial and serves both civilian and military interests.

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TRAINING IN THE ARMED FORCES MEDICAL SERVICE (Fig. 15-19) As mentioned above, only male Swiss citizens are liable to serve in the military, while women can serve voluntarily. The proportion of women in civilian medical professions and medical assistant professions is constantly increasing. Approximately 60-70% of medical students in Switzerland are women and the trend is rising. Of the remaining 30-40% men, approximately half are foreign nationals. Thus, only

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Fig. 14: Position of the Military Medical Services within the Swiss Armed Forces.

Fig. 16: Training in the Armed Forces Medical Service.

Fig. 17: Training in the Armed Forces Medical Service.

Fig. 18: Training in the Armed Forces Medical Service.

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a small pool for recruitment remains. However, with tremendously attractive training prog rammes that greatly benefit medical students before and during their studies, in recent years, the SAFMS has been able to vastly increase interest. Training starts with an extremely shortened period of five weeks at the recruit school, which includes basic military and medical service training such as self-aid and buddy care, etc. The next step in the training is the international certificate level of Pre-hospital Trauma Life Support – Advanced Provider (PHTLS ®AP). This certificate is acquired before the individual begins his or her medical studies and, should they choose to do so, makes it possible for them to work as an emergency medical technician. Fig. 19: Training in the Armed Forces Medical Service. Furthermore, it allows medical students to gain experience in emergency medicine and gives them a head start that may motivate them to excel in their studies. In addition, this training gives students the opportunity to earn money during their studies. From the very beginning, they are trained in leadership and self-management, which gives them the ideal prerequisites for successfully completing their studies. As the Bologna system has been implemented in Switzerland, no further military service is required during the studies until the clinical elective year. In that year, emergency medical training is completed over eight weeks. This counts fully towards study period, with the certificated studies of ATLS ® (Advanced Trauma Life Support), ACLS ® (Advanced Cardiovascular Life Support), a field service physician course and an introduction to war and disaster medicine course, together with leadership training for the medical field. This first-rate training programme is increasingly proving attractive to women. They enter the Armed Forces voluntarily as well as through the Red Cross Service. The duration of military training at the Red Cross Service is shortened, while overall training time is extended with training in applied intercultural skills. These young women and men complete their military physician training with an excellent package of training and experience. Civilian heads of hospital clinics often prioritise young doctors with these qualifications when hiring medical staff. In the area of pharmacy and veterinary medicine, the SAFMS is working to pursue similar paths with very attractive, certificated civilian training. This also fully counts towards their studies and in some cases towards post-graduate training. ORGANISATION OF THE ARMED FORCES MEDICAL SERVICE The Armed Forces Medical Service is part of the Armed Forces Staff and employs around 240 staff members. The organisation is illustrated in Figure 20. The Armed Forces Medical Service has its own medical support battalion in the logistic brigade with a pool of 1,500 medical personnel (reserve) for barracks medical support and other medical specialists. Further resources for medical support in operations and training are: • 1x Role 1 enhanced (single-term conscripts – rapid reaction teams, 6h readiness) in the logistics training brigade; • 48x Role 1 enhanced (24h readiness) in the logistic training Fig. 20: Organization of the Directorate of the Armed Forces Medical Services. brigade; • 4 hospital battalions in the logistics brigade (24h readiness, capacity of 200 beds each); • 1x prehospital medical service corps training; • 1x reserve military hospital (100 beds); • 1 medical logistics support battalion for production of pharmaceuticals and medical logistics; • 100x Role 1 medical support for each battalion (12 bat); • 4 medics with field/armoured ambulance, in each company with combat tasks, providing advanced life support (PHTLS ® first responder) and transport with ambulances (civilian rescue vehicle standard); • specialist medical support for special operations; • 2 medical service corps training institutions running the schools for hospital troops, barracks medical support, field medical support troops, specialised medics and medical doctor officer function; • uniformed Red Cross service organisation with medical specialist and medical service corps support. PRINCIPAL TASKS Surgeon General/ Commissioner of the Federal Council This position includes multiple functions (Fig. 21): • Head of the Armed Forces Medical Service

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• Commissioner of the Federal Council – a position which includes the two functions of head of the Coordinated Medical Services and head of the Centre of Competence for Military and Disaster Medicine; • medical advisor to the Chief of the Armed Forces and to the head of the Federal Department of Defence, Civil Protection and Sport; • responsibility for the medical and technical standards of the Armed Forces Medical Service and of the Red Cross Service organisation according to Swiss laws and civilian standards. Military Medical Services The head of the Military Medical Services also takes on Fig. 21: Multiple functions of Major General Andreas STETTBACHER. the role of Deputy Surgeon Genera l. He is responsible for: • medical recruitment, basic medical care and specialised medical services; • the development of SAFMS policy and doctrine; • business and organisational development; • coordinating the Armed Force Medical Services' international activities (e.g. cooperation with NATO). Armed Forces Nursing Service This area is responsible for: • all aspects of nursing within the SAFMS, including personnel management, planning and controlling; • compliance with current civilian nursing standards; • defining doctrine and training in military nursing. Armed Forces Pharmacy The Armed Forces Pharmacy is divided into four sub-areas: pharmaceutical development, production and quality assurance of medical products, and medical logistics including the procurement of medical and pharmaceutical goods. The main task of the Armed Forces Pharmacy is to ensure the emergency production capacity and an emergency stockpile of essential pharmaceuticals for the Armed Forces and the Swiss population. The pharmacy keeps a list of approximately 100 essential medications, some of which can be produced on the spot while the others are kept stocked. This includes all galenic forms and groups of medication for military and civilian use. The Armed Forces Pharmacy is responsible for: • the preparation of emergency medicine supplies; • the material readiness of the SAFMS, and it is the procurement agency for medical drugs, pharmaceutical and medical supplies; • maintaining and supervising medical aspects and technical hospital material of the SAFMS according to Swiss and international laws and civilian quality standards; • providing the specialised technical material and consumables needed to ensure the operational readiness of the military hospital, and of the main production and storage facilities of the Armed Forces Pharmacy itself, as well as of the seven protected underground treatment facilities of civilian hospitals under special contract with the CMS; • providing the troops with specialist technical assistance for the medical support infrastructure; • the planning, control and quality assurance of work and production processes, pharmaceutical raw materials, medicinal preparations, chemicals, packaging materials and medical products.

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Office of the National Coordinated Medical Services (Fig. 22) This office also comprises several areas: • it is managed by the Surgeon General in his function as Commissioner of the Federal Council; • it is the permanent national network for the coordination and steering of all national medical support assets in extraordinary situations of national dimensions, major disasters and war; • it is responsible for the permanent real-time overview of available civilian and military medical resources; • it develops the fundamental concepts for education and training of the civilian medical services in preparation for major disasters and emergencies and is responsible for the specialised communication and management network.

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Fig. 22: Structure of the Coordinated Medical Services.

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Centre of Competence for Military and Disaster Medicine (Fig. 23) This centre: • develops training directives and defines the content of military medical education and training programmes in cooperation with civilian partners and military medical expert centres of the medical faculties of Swiss universities; • promotes and steers research in military and disaster medicine in cooperation with military and civilian partners (e.g. universities); • ensures national and international certification of military medical education and training. Medical Service Corps Operational Support This service corps: • supports the Armed Forces with medical planning support Fig. 23: Organization of the Centre of Competence for Military and Disaster Medicine. by order of the Chief of the Armed Forces; • develops the training programmes for the Armed Forces Medical Corps as well as the individual soldiers' first aid and medical instruction; • coordinates cooperation between the Red Cross Service and the Medical Corps; • provides specialist support to the Surgeon General; • is responsible for managing education and training for medical services according to existing standards. Armed Forces Veterinary Service This service is responsible for: • developing its own doctrine and policy at strategic, operational and tactical levels; • the Food Hygiene Inspectorate of the Armed Forces and the deployment of food safety inspectors; • the health of the animals of the Armed Forces (preventive and curative care); • education and training of veterinarian officers; • the acquisition and operational planning of military dogs and working horses; • the control of zoonotic disease within the Armed Forces; • quality monitoring of the water supply in facilities of the Armed Forces. The Medical Inspectorate Is responsible for: • leading and controlling cross-cutting areas (e.g . IT, finance, infrastructure, human resources); • drafting a nd imple ment ing directives for cross-sectional areas; • the overall business management in its sphere of responsibility; • coordinating the cooperation with the ICMM; • leading and coordinating the risk management. SWISS MEDICAL SERVICES AND INTERNATIONAL DEPLOYMENTS Switzerland is bound by international-law obligations and can consequently only participate in peacekeeping and peace-building measures. Switzerland’s largest deployment is currently that to Kosovo (Fig. 19 and 24). At the same time, two platoons of medical personnel with single-term conscripts are kept ready for emergencies in Switzerland. These platoons can each operate one first aid station, equivalent to a Role 1 enhanced. Switzerland collaborates closely and successfully with Germany, France, Austria and the USA in its deployments abroad. As far as deployments are concerned, Switzerland cooperates with all partners that work in the same area and with the same objectives, and respect to our national standards. The SAFMS has a mandate from the ICMM to carry out the Law of Armed Conflict (LOAC) course and the workshop on military medical ethic, and to coordinate its dissemination worldwide. These courses are held on an annual basis, are neutral in nature, and aim to impart a general understanding of law of war and military medical ethics matters. The LOAC course can be held, in consultation with the ICMM, on any continent. As a PfP nation within the framework of NATO, Switzerland profits from NATO’s training opportunities Swiss specialists, in turn, hold workshops and congresses for the benefit of NATO. Within the network of bilateral treaties, expansion of certain deployments is possible under UN or OSCE mandates. Further smaller individual projects with various partner nations exist also. In any case, these deployments must serve common interests.

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Fig. 24: Kosovo Force (KFOR) - Swisscoy Mowag Duro IIIP Ambulance.

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BIBLIOGRAPHY 11 © 2018 Basel Tourismus (with permission), info@basel.com 12 https://en.wikipedia.org/wiki/ Basel 13 Statistisches Amt (official site). Basel Kompakt. Statistisches Amt, Präsidialdepartement des Kantons Basel-Stadt. Retrieved 01.09.2015. 14 Vienna tops Mercer’s 19th Qua lity of Living ranking. Mercer.com. 14.03.2017. Retrieved 31.03.2018. 15 https://theculturetrip.com/europe/switzerland/articles/the-most-impressive-buildings-in-basel-switzerland/ 16 Eröffnung des Panzernashornhauses. Archived 21.02.2014 at the Wayback Machine. Zoo Basel, written 26.09.2006, retrieved 03.12.2009. 17 Basler Zeitung. Zoo celebrates 50 years of flamingo breeding. 13.08.2008. Retrieved 21.03.2010. 18 Forbes Travel. GetListy, retrieved 26.03.2010. 19 https://en.wikipedia.org/wiki/Switzerland 10 Federal Chancellery, Communication Support. The Swiss Confederation: A brief guide 2018. Federal Office for Buildings and Logistics FOBL, Publication Distribution, 3003 Bern, Switzerland. Art. No. 104.617.e. www.bundespublikationen.admin.ch 11 Wikipedia, By Hayden120 and NuclearVacuum - File: Location European nation states.svg. This W3C-unspecified vector image was created with Inkscape., CC BY-SA 3.0, https://commons.wikimedia.org/w/ index.php?curid=8109256 12 Swiss Alps Jungfrau-Aletsch. UNESCO World Heritage Centre. 2007. Archived from the original on 21.03.2015. Retrieved 27.03.2015. 13 ©Alpin-Center. https://www.zermatt.ch/en/ Media/ Media-corner/ Photo-database/Summer-Activities/ Mountain-climbing/ Mountaineering-Alpin-Center 14 Report for Selected Countries and Subjects: Switzerland. Washington, DC, U.S.: International Monetary Fund. Retrieved 01.10.2017. 15 Simon Bowers. Franc’s rise puts Swiss top of rich list. The Guardian. London, UK. Archived from the original on 12.01.2016. Retrieved 14.12.2015. 16 Schengen Visa Countries List – Schengen Area. Schengen VISA Information. Archived from the original on 4 December 2015. Retrieved 04.12.2015. 17 History of Switzerland Archived 08.05.2014 at the Wayback Machine. Nationsonline.org. Retrieved on 27.11.2009. 18 Daley C, Gubb J. Healthcare Systems: Switzerland. Civitas, 2013. 19 Kim T. Why does Switzerland do so well in university rankings? The Guardian. London. Archived from the original on 03.10.2014. Retrieved 12.10.2014. 20 Ranking by Top Universities Archived 29.07.2016 at the Wayback Machine. 21 Henri Dunant, the Nobel Peace Prize 1901 Archived 26 April 2011 at the Wayback Machine. nobelprize.o rg . Retrieved on 02.12.2009. 22 European Year of Intercultural Dialogue Dr Michael Reiterer. Retrieved on 1.12.2009. 23 Sports directory Archived 03.05.2010 at the Wayback Machine. if-sportsguide.ch. Retrieved on 25.01.2010. 24 Statistical Yearbook of Switzerland 2018 by Swiss Federal Statistical Office, Zürich 2018, FSO number nzz_jb_2018, Published on 20.03.2018. 25 Six Swiss companies make European Top 100. swissinfo.ch. 18.10.2008. Retrieved 22.07.2008. BASEL, S WITZERLAND AND THE S WISS A RMED FORCES MEDICAL SERVICES By Zeno STANGA, Nej la GÜLTEKIN, Daniel FLÜCKIGER, Fabian ALDCROFT, Thomas BÜHRER and Andreas STETTBACHER. Federal Department of Defence, Civil Protection and Sport DDPS, Armed Forces Staff, Medical Services, Worblentalstrasse 36, CH-3063 Ittigen, Switzerland www.vtg.admin.ch/de/organisation/ lba/sanitaet.htlm

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H1N1 Outbreak Onboard A Warship: Ethics of Vaccination, To Give or Not To. By A. GUPTA∑, N. GOYAL∏, S. RAYπ, N. CHAWLA∫ and P. CHAUHANª. India

Arun GUPTA Surgeon Commander Arun GUPTA is Classified Specialist (Community Medicine). EDUCATION MBBS: AFMC - 2005. MD (Community Medicine): AFMC - 2013. DNB (Social & Preventive Medicine) - 2014. MBA (Health Care Sciences): SIKKIM MANIPAL UNIVERSITY - 2015. PGD (Medical Ethics): NATIONAL LAW SCHOOL, Bengaluru - 2016. WORK EXPEREINCE 2006-2010: As Medical Officer providing combat medical care to various Operational Units of the Indian Navy. 2010-2013: Residency in Public Health. 2013-2017: Instructor at Air Force Academy & Institute of Naval Health. 2017 till date: Station Health Officer of one of the Naval Bases of the Indian Navy. PUBLICATIONS 5 Papers in Indexed Journals. Co-editor of three books. AREA OF INTEREST Ethics in Medical Care, Bio-medical waste Management.

RESUME Epidémie de grippe H1N1 à bord d’un bateau de guerre : vacciner ou pas Contexte : Une épidémie de grippe H1N1 peut constituer un cauchemar de santé publique. Avec un potentiel élevé de diffusion en raison d’un environnement confiné, les spécialistes de santé publique sont très sollicités pour prendre des contre-mesures visibles telles que la vaccination. Obj ectif : Cet article a pour but de décrire les problèmes éthiques et les discussions autour de la question de savoir s’il faut ou non vacciner lorsque survient une épidémie à bord. Résultats : L’analyse des données recueillies montre que l’âge moyen des cas cliniquement suspects était de 26, 71 ans. Parmi les 2 1 cas suspects 14 ont été confirmés positifs. Le taux d’attaque était de 4,83 % et le taux de létalité de 0. Questions éthiques. La question était de savoir si l’on pouvait exposer au vaccin une population j eune et en bonne santé, si la souche responsable était la même que celle contenue dans le vaccin, le rapport coût-efficacité de la vaccination et les incidences économiques.

Conclusion : La vaccination ne j oue aucun rôle si des mesures préventives sont mises en place en temps voulu et de manière efficace. Il n’apparaît pas correct d’administrer à un équipage, un vaccin dont le rapport coût-efficacité n’est pas favorable, dont la souche n’est pas forcément identique à celle qui circule, dont l’efficacité n’est pas prévisible et en l’absence de risques documentés.

KEYWORDS: Ethical dilemma, Warship, H1N1 influenza, Outbreak, Vaccination. MOTS -CLÉS : Questions éthiques, Bâtiment de guerre, Grippe H1N 1, Epidémie, Vaccination.

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restricted air-conditioned environment 1, which may lead to a high morbidity of the ship’s company and compromise the operational deployment of the warship. With studies reporting Secondary Attack Rate (SAR) to touch

INTRODUCTION H1N1 Influenza outbreak on-board a Warship is public health nightmare. It has potential of rapid spread in

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45%2 and strict isolation and quarantine near impossible on-board, there is an enormous pressure on Public Health specialists to undertake tangible medical interventions like vaccination, besides, general measures such as hand washing and cough etiquettes. Vaccination is the only medical intervention that has been credited with the successful elimination of a disease in the past. However, the warships crew is a healthy, young population, in which it cannot be assumed that disease burden, strain prevalence, vaccine efficacy and effectiveness, will justify the use of a vaccine. In addition, the issues of availability, economics, and risk: benefit ratio will have to be taken into consideration before exposing warships’ crew to the H1N1 vaccine3 . Therefore, the issue of vaccination which seems innocuous and straightforward are much more complex than it would seem at a first glance.

definition; Attack Rate (AR), and Case Fatality Ratio (CFR) of H1N1 were calculated. The epidemic curve was drawn to study the distribution of cases in time. Area map to know the geographical distribution of all the cases was plotted. Active surveillance was continued for 14 days (twice the incubation period of H1N1) from the reporting of the last case to assess the effect of the employed control measures and detection of any fresh case.

RESULTS The warship had a predominantly young population. Data in this study elicited mean age of the suspected cases as 26.71 years (with standard deviation ± 6.00 years) (Table 1). Epidemic curve of this outbreak demonstrated an explosive pattern (Fig. 1). Within seven days from the first case, sudden increase in the number of cases was Table 1: Age and Sex Distribution of cases.

The aim of this article is to describe the ethical issues and challenges involved in whether, to vaccinate or not the Ship’s company, in successful control of the H1N1 outbreak on-board a warship.

CHARACTERISTICS

PERCENTAGE %

21 - 25 years

57.14

26 - 30 years

19.04

31 - 35 years

14.28

36 - 40 years

4.76

41 - 45 years

4.76

1. Male

100

2. Female

Nil

Age

MATERIAL AND METHODS Data collection. Primary data was collated from the documents available on-board the Warship and from the hospital where the cases were treated. Secondary data was collected from the health reports sent to the formation headquarters by the warship and the treating hospital. All cases of fever, upper and lower respiratory tract infections occurring among personnel on board, starting from the index case, were listed. Details on demography, residence, date of onset of symptoms, clinical details, results of lab investigations, history of travel, and history of contact with positive case of Influenza (H1N1) were collected from these cases.

Sex

Figure 1: Ep idemic curve of the H1N1 Outbreak.

Case definition. A suspected case of H1N1 Influenza is defined as a person with acute febrile respiratory illness (fever [>100.0°F]) with an onset within 7 days of close contact with a perso n, who is a confirmed case of Influenza A (H1N1) 2009 virus infection, or within 7 days of travel to areas where there are one or more confirmed cases or resides in a community where there are one or more confirmed cases of Influenza A (H1N1) 2009 cases. A confirmed case is defined as an individual with laboratory-confirmed new Influenza A (H1N1) virus infection by one or more of the following: realtime reverse transcriptase-polymerase chain reaction (RT-PCR), viral culture, or 4-fold rise in new Influenza A (H1N1) virus-specific neutraliz ing antibodies4, 5.

∑ Surg. Cdr. OiC Station Health Organization, INS Kadamba. ∏ Surg. Cdr. OiC Lab Sciences, INHS Patanjali. π Surg. Capt. SSO (Health).

Laboratory investigation. Oropharyngeal swabs were collected in sterile viral transport medium and transported under cold chain to the Haffkine Institute (Nodal Institute for H1N1 Influenza A testing in the City of Mumbai), for RT-PCR using the CDC/WHO testing protocol6 . Suspected case confirmed by RT-PCR were considered as confirmed case of the disease5.

∫ Surg Rear Admiral Executive Officer, INHS Asvini. ª Surg. Cdr. Medical Specialist, INHS Asvini. Correspondence: Surg. Cdr. Neeti GOYAL OiC Lab Sciences INHS Patanjali Naval Base IND-581 308 Karwar, India E-mail: neeti.nits@gmail.com

Data analysis. Cases were identified based on the case

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observed. Over three weeks in June 2017, 21 patients reported to sickbay with Influenza like illness (ILI), of which 14 cases turned out to be H1N1 influenza positive after lab investigation.

In 1976 the vaccination program in the United States against H1N1 influenza was discontinued as it was thought to be associated with a concomitant increase in GuillainBarre syndrome (GBS)13. Therefore, as the scientific basis for the effectiveness of specific interventions continues to be studied and models projecting the course of a pandemic being investigated, sound scientific evidence for proposed interventions may not currently exist14. Therefore, it is important to assess disadvantages against benefits before undertaking a mass vaccination program15.

The AR and CFR of H1N1 influenza during the 21-day period was 4.83% and nil, respectively. Confirmation of Outbreak was done comparing the H1N1 cases of the previous years in the same class of warships in the fleet. Number of cases of H1N1 Influenza during same period during last two year in those warships was nil. As the cases were clearly in excess of two standard error, which is defined arbitrary limit of threshold for influenza7, outbreak of H1N1 was confirmed.

Strain responsible for outbreak. Second ethical dilemma is about the strain of the H1N1 Influenza responsible for the outbreak. The strain of H1N1 Influenza may be different from the stain present in the vaccine due to natural evolution of antigenic shift and drift16. New H1N1 strain, called A/Michigan/45/2015, had replaced the 2009 strain A/California/7/2009 during this period17. It cannot be assumed that available vaccine, vaccine efficacy and effectiveness (how well a vaccine works in clinical trials) will be beneficial without molecular level confirmation. Differences in genotype and health status of individuals could affect how their immune system responds to a given immune stimulus. Also, it is pertinent to be brought here that vaccination against influenza is supposed to be renewed and administered yearly according to new circulating strains. This besides acceptability and feasibility, it introduces issue of cost.

From the data collected it was ascertained that H1N1 vaccine was not part of routine immunization program for the Naval personnel. None of the warships’ crew on-board was therefore vaccinated against the disease, but there might be some who had subclinical infections, and thus be sero-positive. Vaccine available in the market at the time of outbreak was effective against H1N1 Influenza Strain A/California/7/2009.

ETHICAL ISSUES/DILEMMAS & DISCUSSION Exposing the young & healthy. First ethical dilemma brought out by the results is, whether it is advisable to expose this primarily young ships-company of the Warship to H1N1 vaccine. The workforce deployed onboard is relatively young and disease free. Those with lifestyle diseases (like Hypertension and Diabetes mellitus) employed onboard have disease free status with medication and no co-morbidities or target organ damage. In this study too, the case fatality rate because of H1N1 Influenza is nil.

Cost effectiveness. Third ethical issue is the cost effectiveness of the vaccine. If the vaccine was to be given, it would have been specially and urgently procured for the ship’s crew, as, it not being part of routine immunization schedule. Vaccine may be unavailable for such a large number of personnel and by the time the vaccine is made available, the outbreak might get mitigated by its natural course. In this study, the AR is 4.83% which was achieved with simple public health interventions like active case finding, strict isolation, and adherence to hand hygiene, following cough etiquettes and disinfection enhancement18. A comprehensive study done on cost effectiveness of H1N1 Vaccine has brought out that, if AR is less than 7.6% then vaccination is not cost effective in low risk sub-groups19.

Dawson in his study described this as the ‘prevention problem’. A concern about the apparent skewed distribution of risks vis-à-vis benefits because of population-based intervention focus of preventive medicine. The key elements of the ‘prevention problem’explained in the study were: a) Public health interventions are executed on asymptomatic persons; b) Every such preventive measure will carry some risk of injury; c) The benefits of such measures are at population level, where-as any risks of harm are borne by the individual undertaking that intervention8, 9.

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Better utilization of scarce resources. Last ethical concern is economics of procuring the vaccine. It would mean the recourses which were allocated for something else, would have to be channelized for procurement of H1N1 vaccine20. Many different ethical principles can be applied to priority-setting in healthcare. The principle of equity requires that the distribution of benefits and burdens be fair. When these principles conflict, the right balance must be determined by a transparent process that takes into account local circumstances21. Isaacs et al. in his research states that the government’s decision-making process should clearly address ethical challenges, as costs of new vaccines increase and the pharmaceutical industry uses disease support groups to lobby on their behalf22. For developing countries, cost is often the paramount issue.

The incidence of Guillain-Barre syndrome (GBS) in the unvaccinated populations averaged 0.97 cases per million people per month across all age groups. However, subsequent studies indicated that risk estimates for GBS attributable to swine flu vaccination in the 6 weeks after immunization ranged from 4.9 to 11.7 cases per million adult vaccines10. A large population-based cohort study in Norway11 had brought out that after pandemic vaccination the adjusted hazard ratio (HR) of GBS was 1.11 (95% CI 0.51-2.43), inferring that vaccination did not increase the risk of GBS. But other study12 done in similar setting, concluded that the higher rate of GBS in first 6 weeks after H1N1 vaccination may be triggered by H1N1 vaccination.

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CONCLUSION Vaccination has no role to play, if preventive measures like active case finding, strict isolation, and adherence to hand hygiene, following cough etiquettes and disinfection enhancement are instituted in time and effectively. It will be in-fact ethically incorrect to expose predominantly young and healthy population to a vaccine intervention which is not cost effective, might have strain which is not active against the virus responsible for the outbreak, has questionable benefits and documented, though not statistically proven risks.

ABSTRACT Background: H1N1 Influenza outbreak on-board a Warship is public health nightmare. With a potential of rapid spread because of confined air-conditioned environment, there is an enormous pressure on Public Health specialists to undertake tangible medical interventions like vaccination. Aim: This article aims to describe the ethical issues and challenges involved in whether, to vaccinate or not the Ship’s company, amidst an H1N1 outbreak on-board a warship. Results: Outbreak data brought out mean age of the clinically suspected cases as 26.71 years. Of 21 suspected cases, 14 were found positive for the disease. The AR and CFR of the disease was 4.83% and nil, respectively. Ethical dilemmas: These were whether it is advisable to expose primarily young and health population to the vaccine, strain responsible for the outbreak is same as available vaccine claims protection to, cost effectiveness of the vaccine and ethical concern in economics of procuring it. Conclusion: Vaccination has no role to play if preventive measures are instituted in time and effectively. It will be infact ethically incorrect to expose ships company to a vaccine intervention which is not cost effective, might have strain which is not active against the virus responsible for the outbreak, has questionable benefits and documented, though not statistically proven risks. Caution Note Conclusion drawn in this article are broadly applicable to the naval warships on routine missions and in harbor. It could be very different in missions undertaken during CBRN threat, in submarines, operations at war and when special forces on-board. Conflict of Interest The authors have none to declare. REFERENCES 11. WHO Interim technical advice for case management of pandemic (H1N1) 2009 on ships, 13 November 2009. Available from: www. who.int/csr/resources/publications/swine u/guidance_ships/en/. [Last accessed on 2018 Mar 28].

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12. MAKRAS P, ALEXIOU-DANIEL S, ANTONIADIS A, HATZIGEORGIOU D. Outbreak of meningococcal disease after an in uenza B epidemic at a Hellenic Air Force Recruit Training Center. Clin Infect Dis 2001; 33: e48-50. 13. ULMER JB, LIU MA. Science and society – vaccines: Ethical issues for vaccines and immunization. Nature Reviews Immunology; volume 2, pages 291–296 (2002). 14. Government of India. Guidelines of Swine flu (Influenza A H1N1), Ministry of Health and Family Welfare, New Delhi; 2010. 15. World Health Organization (WHO). A Practical Guide to Harmonizing Virological and Epidemiological Influenza Surveillance; 2008. Available from: http://www.wpro.who.int/entity/emerging_diseases/ documents/GuideToHarmonizingInfluenzaSurveillance-revised2302/ enlindex.html. [Last accessed on 2017 Apr 07]. 16. World Health Organization. CDC Protocol of Real-time RTPCR for Influenza A (H1N1). Available from: h t t p : / / w w w . w h o . i n t / csr/resources/publications/swineflu/CDCRealtimeRTPCR_S wineH1Assay-2009_20090430.pdf. [Last accessed on 2017 Apr 12]. 17. ROHT LH, SELWYN BJ, HOLGUIN AH, CHRISTENSEN BL. Principals of epidemiology, A self-teaching Guide, New York: Academic Press, 1982. 18. DAWSON A. Vaccination and the prevention problem. Bioethics 2004; 18: 515-530. 19. SHARON KLING. vaccination and ethical issues. Current Allergy & Clinical Immunology, November 2009 Vol 22, No. 4. 10. NACHAMKIN I, SHADOMY SV, MORAN AP, et al. Anti-ganglioside antibody induction by swine (A/NJ/1976/H1N1) and other influenza vaccines: insights into vaccine-associated Guillain-Barre syndrome, J Infect Dis, 2008, vol. 198: 226-33. 11. GHADERI S, GUNNES N, BAKKEN IJ, MAGNUS P, TROGSTAD L, HÅBERG SE. Risk of Guillain-Barré syndrome after exposure to pandemic influenza A (H1N1) pdm09 vaccination or infection: a Norwegian population-based cohort study. Eur J Epidemiol. 2016 Jan; 31 (1): 67-72. 12. SOUAYAH N, YACOUB HA, KHAN HMR, MICHAS-MARTIN PA, MENKES DL, MAYBODI L, QURESHI AI. Guillain-Barré Syndrome after H1N1 Vaccination in the United States: A Report Using the CDC/FDA Vaccine Adverse Event Reporting System (2009). Neuroepidemiology 2012; 38: 227–232. 13. STOWE J, ANDREWS N, WISE L, et al. Investigation of the temporal association of Guillain-Barre syndrome with influenza vaccine and influenza like illness using the United Kingdom General Practice Research Database. Am J Epidemiol 2009; 169: 382-388. 14. KINLAW K, BARRETT DH, LEVINE RJ. Ethical guidelines in pandemic influenza: recommendations of the Ethics Subcommittee of the Advisory Committee of the Director, Centers for Disease Control and Prevention. Disaster Med Public Health Prep. 2009 Dec; 3 Suppl 2: S185-92. 15. PRATEEK BHATIA. The H1N1 influenza pandemic: need for solutions to ethical problems. Indian Journal of Medical Ethics. Oct 2013; 10 (4): 259-63.

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16. BALGOPAL MM, BONDY C. Antigenic Shift and Drift. Science teacher (Normal, Ill.) 283 (5747). January 2011.

influenza A (H1N1) vaccination in the United States. PLoS One 2011; 6: e22308.

17. Recommended Composition of Influenza Virus Vaccines for Use in the 2017-2018 Northern Hemisphere Influenza Season. Available from: http://www.who.int/ influenza/vaccines/virus/ recommendations/201703_recommendation.pdf? ua = 1. [Last accessed on 2017 Oct 06].

20. DEVNANI M, GUPTA AK, DEVNANI B. Planning and response to the influenza A (H1N1) pandemic: ethics, equity and justice. Indian J Med Ethics. 2011 Oct-Dec; 8 (4): 23740.

18. GUPTA A, RAY S, TYAGI R, KUMAR A. Control of H1N1 influenza outbreak: A study conducted in a naval warship. J Mar Med Soc 2017; 19: 142-5.

21. World Health Organization. Ethical considerations in developing a public health response to pandemic influenza [Internet]. Geneva: WHO; 2007. Available from: http://www.who.int/csr/ resources/ publications/WHO_CDS_ EPR_GIP_2007_2c.pdf. [Last accessed on 2017 May 03]

19. PROSSER LA, LAVELLE TA, FIORE AE, BRIDGES CB, REED C, JAIN S, et al. Cost-effectiveness of 2009 pandemic

22. ISAACS D, KILHAM H, LEASK J, et al. Ethical issues in immunisation. Vaccine 2009; 27: 615-618.

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A RT ICLES

Fluid Resuscitation in Trauma-Looking Beyond the ATLS Recommendations.* By R. SETLUR. India

Rangraj SETLUR Brigadier Rangraj SETLUR MB, BS, MD, DNB, MRCPI is Member of The Royal College of Physicians, Ireland 2011. He is member of the Fellowship in Critical Care Medicine University of Iowa Hospitals and Clinics, USA (2000-2001) and Fellowship in Cardiac Anesthesia, University of Iowa Hospitals and Clinics, USA (2001-2002). He was awarded Diplomate of the National Board of Examiners (DNB) in Anesthesiology (1998). He obtained his degree of MD Anesthesiology at the University of Pune, India (1995), MB BS, AFMC (1987) He is Instructor Advanced Trauma Life Support (American College of Surgeons 2002-2005), Instructor Advanced Cardiac Life Support (American Heart Association 2002-2005), Instructor Fundamentals of Critical Care Support (Critical Care Medicine). He was Associate Professor at Maharashtra University of Health Sciences (2007- 2008), Professor at University of Delhi, Faculty of Medical Sciences (2011-2014), Professor at Raj iv Gandhi University of Health Sciences, Karnataka (2014-2016), and Professor at West Bengal University of Health Sciences since 2016. Brigadier Rangraj SETLUR is Consultant (Anaesthesiology) at the Command Hospital (Eastern Command) in Calcutta since 2016. He is Head of the Department of Anaesthesia, Command Hospital (Air Force) Bangalore. He was posted as Senior Advisor (Anaesthesiology) at the Army Hospital R&R in New Delhi (2011-2014) and 167 Military Hospital (2008-2011). He was Associate Professor at the Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune India (2002-2008). He was Fellow at the Departments of Critical Care and Cardiac Anaesthesia, University of Iowa Hospitals and Clinics, USA 2000-2002. He was Classified Specialist at the Military Hospital, Secunderabad, (1997 -2000) and Graded Specialist (Anaesthesiology) 2121 Field Ambulances (1995-1997). He succeeded the Advanced Course (Anaesthesiology) at Armed Forces Medical College, Pune, India (1991-1994). He was Medical Officer at 416 Field Ambulances (1988-1991) Brigadier Rangraj SETLUR is author and co-author of several publications in national and international journals.

RESUME Le soutien médical aux opérations du Service de Santé du Royaume Uni Au-delà des recommandations de l’ATLS, quelles modalités de remplissage suite à un traumatisme ? La récente édition de directives avancées pour la réanimation après traumatisme a introduit des changements substantiels concernant les liquides de remplissage utilisés. Une revue de la littérature actuelle a été réalisée pour envisager les évolutions susceptibles d’apparaître dans les années à venir, particulièrement pour ce qui concerne les traumatismes des militaires.

KEYWORDS: Fluid Therapy, Rehydration Solutions. MOTS -CLÉS : Thérapie de remplissage, Solutions de réhydratation.

fluid management in trauma patients. Over the years, the philosophy has changed from emphasising organ perfusion to an approach of where clot stabilisation has been given priority practically to the exclusion of everything else. Given the recently introduced 10th edition of the ATLS guidelines it may be helpful to consider how

INTRODUCTION Sometimes changes in medicine happen so imperceptibly that it is only when one looks back over a period of ten to twenty years that one realises how much the landscape has altered. This applies especially to prehospital

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we got here and speculate about where we might be going from here.

the crystalloids all the way down to one litre comes in part from a database analysis by Hussmann5 who matched 1896 patients who had sustained trauma into two groups, in which all the relevant trauma related characteristics were similar except for the amount of crystalloids given. One group received less than 1500 ml (a mean of slightly over a litre) and the other received more than 1500 ml (a mean of 2648 ml). The only significant difference on admission between the two groups was the quantum of crystalloids they received, but in the period following admission, the high-volume group received significantly more massive transfusions, blood transfusions, and had a significantly lower haemoglobin, and worse indicators of coagulation.

ASSESSMENT OF BLOOD LOSS The standard ATLS classification (0-15%,15-30%,3040% and more than 40%) have been ingrained in the assessment of trauma. But what should be the approach if the blood pressure indicates class IV haemorrhage but the heart rate only indicates a class I haemorrhage? This happens more frequently than one may think. In 15-25% of significant haemorrhages, there is a relative bradycardia, possibly due to the vagal effect of intraperitoneal blood. Muntschler et al1 looked at a database of over 30,000 patients and found that 9.3% of patients fitted in all criteria into one of the classes of the ATLS schema. The other 90% did not fit into any of the categories since at least one of the vital signs belonged to a discordant class. It is questionable how useful a classification system is, which accurately identifies only one out of ten patients. The author proposed adding base deficit to the classification2. Base deficit has been found to be far more discriminatory than the clinical criteria. Curiously, studies using serum lactate as a discriminant proved far less successful3.

CHOICE OF FLUID We have known for a number of years that normal saline is not really normal- it has chloride levels much higher than is seen in human physiology, and for that reason it causes a hyperchloremic metabolic acidosis. But finding a clinical relevance for this finding has been challenging. Zampieri6 looked at critically ill patients admitted to an ICU. After controlling for age, weight, gender, major comorbidities and scores for illness, there was clear inverse correlation between the quantum of Ringers lactate used and mortality. This applied especially when large volumes of fluid were given. It is arguable how relevant this is to trauma patients, but in the absence of trauma specific studies, the presence of a physiologically plausible explanation for the outcome, and the low cost involved in making the choice, there seems no reason not to use Ringers Lactate (or one of its equivalent surrogates) as the fluid of choice. Hypertonic fluid studies have been largely abandoned due to futility7, and as far as colloids are concerned, if one eliminates articles which have been withdrawn due to fraud, colloids trend to a worse outcome, both in the ICU and in trauma. It must be said here the data for worse outcomes for colloids in trauma is far weaker 8, and there are still situations where colloids are preferable. For instance, a medic carrying fluids into battle would find that colloids are far more practicable to carry, when examined from the point of view of weight carried and volume expansion achieved. The same logic may also apply to hyp ertonic saline as a resuscitation fluid.

Even with this extra discriminant, the situation is still unsatisfactory, since it does not answer the key question: how much reserve does the body have? Convertino et al4 set up an experimental simulation in which volunteers were placed in steadily increasing negative pressures, thus causing pooling of blood in the lower extremities and simulating graded blood loss. Simultaneously arterial waveform analysis was carried out. One of the surprising features of the experiment was that volunteers who were highly tolerant of shock, had a higher shock index than volunteers who were less tolerant, indicating perhaps that they were more capable of defending the fall in cardiac output because of a decrease in stroke volume bay an increase in heart rate. They also found that changes in the variability of their arterial wave form contours which correlated with how much compensatory reserve there was. It is conceivable that analysis of the data so obtained could form the basis for a proprietary device which analyses compensatory reserve and allows more accurate targeting of resuscitation.

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The concept of trauma induced coagulopathy has been refined over the years to emphasise the importance of ongoing fibrinolysis as a critical part of the pathophysiology of bleeding in trauma, and this has led to the introduction

This is where the second remarkable change has come. The prehospital fluid allowance has been dropping over to the years till the current recommendations which suggest just one litre of crystalloid. This remarkable change has been spurred by numerous articles both from the laboratory as well as from pragmatic trials. Laboratory studies have repeatedly showed that increased crystalloids dilute coagulation factors and reduce the ability to clot and clot strength. In addition, volume expansion and increased pressures before definitive hemostasis has been achieved is likely to dislodge loose clots and worsen bleeding. The current recommendation for reducing

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Correspondence: Brigadier Rangraj SETLUR Department of Anaesthesia Consultant, Command Hospital (Eastern Command), Alipore Road, Alipore Kolkata IND-700027 West Bengal, India E-mail: rangraj@gmail.com * Presented at the 42nd ICMM World Congress on Military Medicine, New Delhi, India, 19-24 November 2017.

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of tranexamic acid, which has now been validated in a number of trials, notably the Crash-2 trial and the MATTERS trial. However, when looked at with dynamic tests of coagulation such as TEG and ROTEM, as opposed to static tests like fibrinogen levels, prothrombin times and APPT, the existence of this dogma has been surprisingly difficult to demonstrate9. There is also the existence in some patients of a fibrinolytic shutdown, which can render the patient hypercoagulable. One of the indicators that there may be a case for more accurately targeting patients requiring tranexamic acid is the improved survival in the tranexamic acid wing. The patients in this study were in general far more severely injured, and presumably were at far greater risk of fibrinolysis. There is at least a chance that the Crash-2 recommendations have resulted in tranexamic acid being used for patients who are not undergoing fibrinolysis, and consequently may be at risk of hypercoagulopathy. Apart from tranexamic acid, another approach which has been widely advocated to reduce trauma induced coagulopathy is using blood, fresh frozen plasma and platelets in 1:1:1 concentrations. This poses obvious logistical problems in the field, and besides, fresh frozen plasma as a source of coagulation factors does not give much bang for the buck. Another approach is to use fibrinogen concentrates instead of fresh frozen plasma. A recent single centre open label trial10 was terminated early because FFP was markedly inferior to fibrinogen concentrate, with 76% of patients reversing their coagulopathy, compared to 27% in the FFP group, and a much lower incidence of massive transfusions. This seems to be an area in which research is likely to be very promising.

these measures have shown epidemiological evidence of being associated with improved mortality compared to the current standard of care16. A number of these changes are being considered for incorporation in the TCCC guidelines17.

CONCLUSION Finally, what does the future look like? Assessing compensatory reserve as a means of assessing shock and fluid requirements, improved targeting of antifibrinolytics using dynamic indicators of coagulation and the replacement of fresh frozen plasma by fibrinogen concentrates are at least some of the changes one can anticipate. For the rest, as always, the future is by definition largely unpredictable.

ABSTRACT The recent edition of the Advanced Trauma resuscitation Guidelines has introduced substantial changes in the fluid resuscitation of trauma. A review of the current literature was carried out to consider further changes which may be introduced in the years to come, with special emphasis on the field of military trauma. REFERENCES 11. MUTSCHLER M, NIENABER U, BROCKAMP T, WAFAISADE A, WYEN H, PEINIGER S, et al. A critical reappraisal of the ATLS classification of hypovolaemic shock: Does it really reflect clinical reality? 2012. 12. MUTSCHLER M, NIENABER U, BROCKAMP T, WAFAISADE A, FABIAN T, PAFFRATH T, et al. Renaissance of base deficit for the initial assessment of trauma patients: a base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU®. Crit Care [Internet]. 2013 Mar; 17 (2): R42. Available from: https://doi.org/10.1186/cc12555

An attractive alternative to whole fresh frozen plasma is lyophilised plasma which can be produced either by sublimation in a vacuum or by spray drying. Either way, except for a 25% reduction in von Willebrand Factor, an acceptable activity profile of coagulant proteins is available in the reconstituted product. The use of large pools of plasma from multiple donors leads to an averaging of the coagulation activity across units. Lyophilised plasma has been utilised in the field with promising results11. With regards to providing oxygen carriage in the form of blood, The Trauma Hemostasis and Oxygenation Research (THOR) Network has suggested that for the moment, maintaining blood flow (as long as it does not increase the risk of bleeding) may be more important than increasing oxygen content, but with this caveat, blood based products do seem to be preferable12.

13. PALADINO L, SINERT R, WALLACE D, ANDERSON T, YADAV K, ZEHTABCHI S. The utility of base deficit and arterial lactate in differentiating major from minor injury in trauma patients with normal vital signs. Resuscitation [Internet]. 2008; 77. Available from: https://doi.org/10.1016/j.resuscitation.2008.01.022 14. CONVERTINO VA, WIRT MD, GLENN JF, LEIN BC. The Compensatory Reserve For Early and Accurate Prediction Of Hemodynamic Compromise. Shock [Internet]. 2016; 45 (6): 580–90. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00024382201606000-00002

GENERALISING APPLICABILITY

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15. HUSSMANN B, LEFERING R, WAYDHAS C, TOUMA A, KAUTHER MD, RUCHHOLTZ S, et al. Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at th. Injury [Internet]. 2013; 44 (5): 611–7. Available from: http://dx.doi.org/10.1016/j.injury.2012.02.004

Do the current recommendations apply in ALL situations? What if one is six hours away from the nearest medical facility? Does the guideline on restricting resuscitation still apply? What if one has to carry fluids on a long patrol, and colloids give a better expansion for an equal weight than crystalloids? There is not enough data to make a clear recommendation in these situations13, but apart from tranexamic acid, other options which are being rediscovered include lyophilised plasma which can be reconstituted, and carrying blood bags14, 15. Interestingly,

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16. ZAMPIERI FG, RANZANI OT, AZEVEDO LCP, MARTINS IDS, KELLUM JA, LIBÓRIO AB. Lactated Ringer Is Associated With Reduced Mortality and Less Acute Kidney Injury in

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Critically Ill Patients. Crit Care Med [Internet]. 2016; 44 (12): 2163–70. Available from: http:// insights.ovid.com/crossref?an=00003246-201612000-00006

12. T HOMPSON P, FRCA RR. Trauma Hemostasis And Oxygenation Research (THOR) Network Position Paper On The Role Of Hypotensive Resuscitation As Part Of Remote Damage Control Resuscitation. 2018; 1-48.

17. DE CRESCENZO C, GOROUHI F, SALCEDO ES, GALANTE JM. Prehospital hypertonic fluid resuscitation for trauma patients. J Trauma Acute Care Surg [Internet]. 2017; 82 (5): 956–62. Available from: http:// insights.ovid.com/crossref?an=01586154-201705000-00019 18. LISSAUER ME, CHI A, KRAMER ME, SCALEA TM, JOHNSON SB. Association of 6% hetastarch resuscitation with adverse outcomes in critically ill trauma patients. Am J Surg. 2011 Jul; 202 (1): 53–8. 19. WALSH M, SHREVE J, THOMAS S, MOORE E, MOORE H, HAKE D, et al. Fibrinolysis in Trauma : “Myth,” “Reality,” or “Something in Between” Fibrinolys is in Trauma : “Myth” or “Reality” Four Theories of TIC and Their Re lation to Fibrinolysis. 1969; 46545.

13. CHANG R, EASTRIDGE BJ, HOLCOMB JB. Remote Damage Control Resuscitation in Austere Environments. Wilderness Environ Med [Internet]. 2017; 28 (2): S124 – 34. Available from: http://dx.doi.org/ 10.1016/j.wem.2017.02.002 14. REILLY DJO, MORRISON JJ, JANSEN JO, APODACA AN, RASMUSSEN TE, MIDWINTER MJ, et al. Prehospital blood transfusion in the en route management of severe combat trauma : A matched cohort study. 2014; 77 (3). 15. LYON RM, DE SAUSMAREZ E, McWHIRTER E, WAREHAM G, NELSON M, MATTHIES A, et al. Pre-hospital transfusion of packed red blood cells in 147 patients from a UK helicopter emergency medical service. Scand J Trauma Resusc Emerg Med. 2017; 25 (1).

10. INNERHOFER P, FRIES D, MITTERMAYR M, INNERHOFER N, VON LANGEN D, HELL T, et al. Reversal of trauma-induced coagulopat hy using first-line coagulation factor concentrates or fresh frozen plasma (RETIC): A single-centre, parallel-group, open-label, randomised trial. Lancet Haematol . 2017; 3026 (17): 1– 14.

16. JONES AR, FRAZIER SK. Increased mortality in adult patients with trauma transfused with blood components compared with whole blood. J Trauma Nurs. 2014; 21(1):22-9. 17. BUTLER FK, HOLCOMB JB, SCHREIBER MA, KOTWAL RS, JENKINS DA, CHAMPION HR, et al. Fluid resuscitation for hemorrhagic shock in tactical combat casualty care: TCCC guidelines change 14-01--2 June 2014. J Spec Oper Med. 2014;14(3):13–38.

11. VITALIS V, CARFANTAN C, MONTCRIOL A, PEYRE S, LUFT A, POUGET T, et al. Early transfusion on battle fi eld before admission to role 2 : A preliminary observational study during “Barkhane” operation in Sahel. 2017.

Dear Colleagues, Partners and Friends of WMA, We invite you to join our conference on the future or our profession, which we will held in Israel May 13th to 15th this year. We will deal with the challenges and opportunities before us, from health technology and artificial intelligence to commercialization and workforce planning. We will address the future of medical education and will ask what a medical workplace should look like to bestserve our patients in the future. Let us sharpen our view for what is ahead of us. Please register on the WMA website. Places are limited and will be given on a first come – first served basis. (Please note this conference will be followed by the European Song Contest – we expect hotel being booked soon.) For registration details, program and schedule, please see the WMA website: www.wma.net/events-post/ 12114/

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A RT ICLES

Profil épidémiologique et clinique des dermatoses chez les réfugiés maliens de Goudebou au Burkina Faso. Par Y. KARABINTA∑, ∏, I. KONATÉ∑, L. CISSÉ∏, O. SY LLA∏, π, M. GASSAMA∑, ∏, A. DICKO∑, ∏, K. COULIBALY∏, π, NANCY WALTERS∫, S. DAO∑, O. FAYE∑, ∏ et S. KEITA∑, ∏. Mali

Yamoussa KARABINTA KARABINTA Yamoussa, Assistant chef de clinique en Dermatologie-Vénéréologie de la Faculté de Médecine et Odontostomatologie de Bamako (USTTB), Praticien hospitalier au Centre Nat ional d’Appui à la lutte contre la Maladie (CNAM, ex Inst itut Marchoux). TITRES ET DIPLOMES • Novembre 2015 : Diplôme d’Etudes Spécialisées de Dermatologie-Vénéréologie, Faculté de Médecine et d’Odontostomatologie, Bamako, Mali. • Octobre 2010 : Doctorat en Médecine, Faculté de Médecine et d’Odontostomatologie, Bamako, Mali. • Juin 2003 : Baccalauréat, série Science Biologique, Lycée Lahaou I TOURE, Bamako, Mali. SCOLARITE • Novembre 2003 : Début des études de Médecine, Faculté de Médecine et d’Odontostomatologie, Bamako, Mali. • Janvier 2011 : Début des études de Spécialité de Dermatologie-Vénéréologie, Faculté de Médecine et d’Odontostomatologie, Bamako, Mali. • Novembre 2015 : Fin des études de Spécialité de Dermatologie-Vénéréologie, Faculté de médecine et d’Odontostomatologie, Bamako, Mali. MEMOIRE (S) ET THESE (S) • KARABINTA Y. Aspects Epidémiologiques et Cliniques du Prurigo chez le PVVIH à l’Hôpital Fousseyni N’DAOU de Kayes. Mémoire, Méd., Dermato., FMOS, Bamako, 2015, 33p. Mention très honorable. • KARABINTA Y. Les Pathologies Thyroïdiennes au Mali : Aspects Epidémiologiques et Histologiques. Thèse, Méd., FMPOS, Bamako, 2010, 478p. Mention très honorable. SOCIETES SAVANTES, CULTURELLES OU SCIENTIFIQUES • Société Malienne de Dermatologie et de Vénéréologie (SMDV). • Société des Dermatologistes Afrique Francophone (SODAF). • Association des Dermatologues Francophones (ADF).

SUMMARY Epidemiological and clinical profile Dermatosis at the malian refugees of Goudebou in Burkina Faso. Introduction: Following the rebellion and terrorism in the Northern of Mali, 10,000 Malians were refugees in the Goudébou camp in Burkina Faso. The prevalence of dermatoses seems to be underestimated in the various refugee camps, where they constitute a maj or health issue with the risk of sporadic epidemics or emergence of infectious dermatoses. The aim of our study was to estimate the prevalence and describe the clinical aspects of dermatoses in the Goudébou refugee camp in Burkina Faso. Material and methods: the study was non-exhaustive, and consisted of a descriptive cross-sectional survey that last for six months from January 1st to June 30th, 2013. The diagnosis of dermatosis was based on clinical examination. We recorded patient’s history and, then we proceed to dermatological clinical examination. Additional examinations were not accessible, thus were not performed.

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Results: Of the 5,42 1 patients examined, 1, 652 (30.5%) cases of clinical dermatoses were recorded in Goudébou camp. Per day we received on average 9. 17 patients in dermatological ward some of which come from themselves and others were referred by our colleagues from other specialties. Seventy-one percent (1173 cases) were female, and children under 18 years old represented 42 % (304 cases). Among the different dermatosis, 603 (36.50%) were infectious, 192 (11.60%) immuno-allergic, 3 16 (19. 10%) chronic inflammatory, and 387 (23.4 %) deficient dermatoses. Conclusion: The high frequency of dermatoses among refugees is related to their hygienic and nutritional conditions, the improvement of which requires the involvement of national and international political authorities.

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MOTS-CLÉS : Epidémiologie, Clinique, Dermatoses, Réfugiés, Goudébou. KEYWORDS: Epidemiology, Clinic, Dermatoses, Refugees, Goudébou.

INTRODUCTION

RÉSULTATS

Le camp de réfugié de Goudebou est l’une des quatre camps de réfugiés du HCR au Burkina Faso. Situé à 130 km de la frontière malienne1, Goudébou, aux portes du Sahel, possède ses tentes en bâches et ses bâtiments en dur, qui parsèment une vaste étendue désertique sur laquelle 10 000 Maliens sur les 32 300 ont trouvé refuge2 . La prévalence des dermatoses semble sous-estimée dans les différents camps de réfugiés où elles constituent un problème majeur de santé avec un risque d’émergence des dermatoses infectieuses. La sous-estimation de cette prévalence est liée au manque d’étude dans ces camps de réfugiés. Le manque d’hygiène et l’insuffisance de nourriture dans les camps exposent ces réfugiés aux dermatoses infectieuses et carentielles.

Au total, 1 652 cas de dermatose sur un total de 5 421 patients consultés durant cette campagne de consultation ont été recensés dans le camp de Goudébou, soit une prévalence de 30,47 % au niveau du camp. Le sexe féminin a représenté 71 % (1 173 cas), le sexe masculin 29 % (479 cas) et les enfants 18, 42 % (304 cas). L’âge moyen était de 42 ans avec les extrêmes de 2 mois et 85 ans. L’interrogatoire minutieux et l’analyse sémiologique des lésions élémentaires ont abouti aux diagnostics suivants : les dermatoses infectieuses qui ont représenté 37,70 % des cas, étaient constituées par des dermatoses bactériennes dans 39,6 % (252 cas) soit 87 cas de furoncle et furonculose, 65 cas d’impétigo, 40 cas d’érysipèle, 31 cas d’hidrosadénite et 29 cas de fasciite nécrosante). Les dermatoses fongiques ont représenté 19 % (114 cas) soit 47 cas de teigne, 25 cas de dermatophyties de la peau glabre, 24 cas de dermatite séborrhéique, 17 cas de pytiriasis versicolor. Les dermatoses virales ont représenté 25 % (153 cas) soit 46 cas d’herpes récurrent, 42 cas de condylomes, 28 cas de varicelle, 20 cas de zona et 14 cas de molluscum contagiosum. Les dermatoses parasitaires ont représenté 14 % (84 cas) soit 56 cas de gale et 28 cas de pédiculose. Les dermatoses carentielles 23,4 % (387 cas) étaient constituées de 58 cas de phrynodermie (VitA), 99 cas de pellagre, (érythème péri orificiel, hyperpigmentation réticulée des pulpes digitales, alopécie partielle) (VitB), 44 cas d’acrodermite enteropathique (Zinc), 155 cas de chéilite angulaire et de koïlonychie (carence martiale) et 31 cas d’ecchymoses et de purpura pétéchial (Vit K). Les dermatoses inflammatoires chroniques 19,10 % (316 cas) soit 126 cas de lichen plan. 111 cas de psoriasis vulgaire et 79 cas de pity riasis rubrapillaire. Les dermatoses immunoallergiques 11,60 % (192 cas) soit 39 cas d‘urticaires, 87 cas d’eczéma de contact, et 66 cas de dermatites atopiques. Les dermatoses tumorales ont représenté 4,20 % (69 cas) soit 14 cas de maladie de Kaposi, 8 cas de botriomycomes, 11 cas d‘angiomes et 36 cas de condylomes. Les dermatoses auto-immunes ont représenté 2 % (31 cas) soit 13 cas de pemphigus/pemphigoïde, 10 cas de lupus

MATÉRIELS ET MÉTHODE Notre étude s’est déroulée dans le camp de réfugié de Goudébou. IL est l’un des principaux camps de réfugié maliens au Burkina Faso3 .

L’étude était exhaustive. Elle a consisté en une enquête transversale à visée descriptive qui s’est déroulée du 1er janvier au 30 juin 2013, soit 6 mois. Les critères d’inclusion ont été les suivants : tous les patients réfugiés vus et consultés dans le camp de Guédébou chez qui le diagnostic d’une dermatose a été retenu sur les arguments cliniques quel que soit l’âge. Le conseil et le dépistage du VIH n’étant pas considérés comme des interventions prioritaires dans les phases précoces au début d’une situation d’urgence parce qu’il ne s’agit pas d’une intervention permettant de sauver la vie dans l’immédiat, le statut VIH n’avait pas été recherché de façon systématique chez nos patients.

∑ Faculté de médecine et d’Odontostomatologie (FMOS). ∏ Centre national d’appui à la lutte contre la maladie (CNAM), Bamako (Mali). π Direction Centrale des Services des Santés de l’Armée (DCSSA). ∫ Camp de Réfugiés de GOUDEBOU.

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Les données ont été recueillies à travers une fiche d’enquête. Le traitement et l’analyse statistique des données ont été réalisés à l’aide du logiciel EPI INFO 6.04 version française et les saisies avec les log iciels Microsoft Word. Le consentement libre et éclairé verbal de tous nos patients a été obtenu avant leur inclusion.

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Correspondance: Dr KARABINTA Yamoussa Maitre-Assistant, FMOS/ USTTB, BP : 251 Bamako (Mali) Tél. : +223 76014532 Email : ykarabinta@yahoo.com

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élevée des dermatoses pourrait s’expliquer par le manque d’hygiène/assainissement et l’insuffisance de personnel médical dans le camp. Ce résultat est comparable à celui de Albares Tendero et al en Espagne qui ont trouvé une prévalence de 41 % des dermatoses dans une étude réalisée en une année chez 706 patients latinoaméricains immigrants dans la Section de Dermatologie du Général Hospitalier d’Alicante4. Il était supérieur à celui trouvé lors d’une étude Canadienne réalisée sur 3 ans sur un total de 6 642 immigrants par Michael et al qui ont trouvé une prévalence 16.2 % de dermatoses (1 076 cas)5. Le sexe ratio F/H était de 2,47. Cette prédominance féminine pourrait être expliquée par le fait que les femmes et les enfants constituent une population vulnérable et qu’ils sont par conséquent priorisés pour l’accueil dans

érythémateux et 8 cas de sclérodermie/dermatomyosite. Les autres dermatoses ont représenté 3,2 % (54) soit 9 cas de vitiligo, 26 cas de pityriasis rosé de Gibert et 19 cas de vascularites non spécifiques et de kystes. Ces dermatoses étaient localisées dans 68, 4 % cas et généralisées dans 31, 6 % des cas. Nous avons recensé 18,8 % (311 cas) de malnutrition aiguë associée aux dermatoses. Cliniquement, ces cas de malnutrition étaient composés de 124 cas de marasme, 76 cas de kwashiorkor et 110 cas de formes mixtes (marasme et kwashiorkor).

DISCUSSION La prévalence des dermatoses dans le camp de réfugiés de Goudebou était donc de 30,47 %. Cette fréquence

Tableau 1: Récapitulatif des types de dermatoses observées chez les réfugiés. TYPE DE DERMATOSES

Dermatoses infectieuses (603)

Dermatoses Carencielles (387)

Dermatoses Inflammatoires (316)

Dermatoses Immuno-Allergiques (192)

Dermatoses Tumorales (69)

Dermatoses Auto-Immunes (31)

Autres Dermatoses (54)

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36,50%

23,4%

19,10

11,60

4,20%

3,2%

Bactériennes

252

Fongiques

114

Virales

153

Parasitaires

Phrynodermie (VitA)

Pellagre (Carence en VitB)

Acrodermite entéropathique (Zinc)

Chéilite Angulaire, koïlonychie (Carence martiale)

155

Ecchymose, purpura pétéchial (Vit K)

Psoriasis

111

Lichen plan

126

Pityriasis rubrapillaire

Eczéma de contact

Dermatite atopique

Urticaire

Maladie de Kaposi

Condylomes

Angiomes

Botriomycomes

Lupus érythémateux

Pemphigus, pemphigoide

Sclérodermie, Dermatomyosite

PRG

Vitiligo

Vascularite non spécifique, kystes

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Figure 1 : Psoriasis en goutte chez un j eune réf ugié.

Figure 3 : Un cas de PRP avec des pap ules kératosiques disséminées.

Figure 2 : Un imp étigo avec des croûtes melicerique chez un nourrisson. Figure 4 : Un cas de Kap osi chez un réf ugié.

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les différents camps de réfugiés. Ce résultat est différent de celui d’Albares Tendero et al en Espagne qui avait trouvé un sexe ratio de 7/3en faveur des hommes. La tranche d’âge de 31-40 ans était la plus représentée avec une moyenne d’âge de 42 ans. Cela pourrait s’expliquer par le fait que les individus de 30 à 40 ans sont plus aptes physiquement à se déplacer que les vieilles personnes et ce résultat est comparable à celui de l’Espagne et du Canada qui ont rapporté respectivement une moyenne d’âge de 37 ans et 41 ans. Cliniquement les dermatoses infectieuses et carentielles ont prédominé dans notre étude et cela pourrait s’expliquer par les conditions hygiéniques défavorables liées aux manques d’eau d’assainissement dans le camp qui les exposent aux dermatoses

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infectieuses. Parmi ces dermatoses infectieuses, l’impétigo, les teignes, le molluscum contagiosum et la varicelle ont été les plus fréquemment observés chez les enfants. Ce résultat diffère de celui obtenu en Espagne chez les immigrants latino-américains où prédominaient les

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dermatoses immuno-allergiques (34,51 %)6 . Les dermatoses carentielles ont suivi les dermatoses infectieuses (36,50 %). Cette fréquence des dermatoses carentielles pourrait s’expliquer par l’insuffisance de nourriture dans le camp. Parmi les cas de dermatoses carentielles, 76 % (294 cas) étaient des enfants dont 60 % étaient associés à un état de malnutrition. L’état nutritionnel de ces enfants a été déterminé selon les critères de l’Organisation mondiale de la santé (alimentation inadéquate, hygiène, soins insuffisants sur longue période, indicateurs de pauvreté et de vulnérabilité, conséquences à long terme) et les signes cliniques de malnutrition. Les dermatoses inflammatoires ont suivi les dermatoses infectieuses et carentielles, et elles étaient dominées par le lichen plan et le psoriasis. Cela pourrait s’expliquer par les situations difficiles, le stress permanent et l’angoisse dans lesquels vivent ces réfugiés, favorisant la survenue de ces dermatoses inflammatoires chroniques. Le conseil et le dépistage du VIH n’étant pas considérés comme des interventions prioritaires dans les phases précoces au début d’une situation d’urgence parce qu’il ne s’agit pas d’une intervention permettant de sauver la vie dans l’immédiat, le statut VIH n’avait pas été recherché de façon systématique chez nos patients. Cependant pour optimiser la prise en charge des patients, les cas de

Kaposi et de condylomes ont bénéficié d’un dépistage du VIH. Nous avions recensé 13 personnes avec une sérologie VIH positive. Ces cas ont bénéficié d’une prise en charge adaptée. Lorsque la situation d’urgence se stabilise, il est important de proposer le conseil et le dépistage du VIH à toutes les personnes qui ont besoin de connaître leur statut sérologique.

CONCLUSION la fréquence élevée des dermatoses dans les camps de réfugiés est sans doute en rapport avec leurs conditions hygiéniques et nutritionnelles dont l’amélioration nécessite l’implication des autorités politiques nationales et internationales.

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RÉSUMÉ Introduction : Suite à la rébellion et le terrorisme dans le nord du Mali, 10 000 Maliens ont trouvé refuge dans le camp de Goudébou au Burkina Faso. La prévalence des dermatoses semble sous-estimée dans les différents camps de réfugiés où elles constituent un problème majeur de santé avec un risque de survenu d’épidémie sporadique et d’émergence des dermatoses infectieuses.

les réfugiés est en rapport avec leurs conditions d’hygiènes et nutritionnelles dont l’amélioration nécessite l’implication des autorités politiques nationales et internationales. Aucun conflit d’intérêts. RÉFÉRENCE 1. HCR (2012), « Synthèse globale des données des réfugiés maliens au Burkina Faso », 30 décembre 2012, http://data.unhcr.org/ MaliSituat ion/country.php?id=26. Les chiffres ne sont pas encore disponibles pour la Mauritanie et le Niger, mais les précédentes estimations indiquaient également une majorité de Touaregs parmi les réfugiés en Mauritanie.

Objectif : Evaluer la prévalence et décrire les aspects cliniques des dermatoses dans le camp de réfugié de Goudébou au Burkina Faso. Matériel et méthodes : l’étude était non exhaustive. Elle a consisté en une enquête transversale à visée descriptive qui s’est déroulée du 1er janvier au 30 juin 2013, soit 6 mois. Le diagnostic de dermatose était établi à partir de l’examen clinique. Nous avons procédé à une anamnèse minutieuse et à un examen clinique dermatologique chez tous les patients. Des examens complémentaires n’ont pas été réalisés à cause de leurs inaccessibilités. Résultats : au terme de notre enquête, nous avons recensé 1 652 cas de dermatoses cliniquement diagnostiqués sur un total de 5 421 patients consultés (toutes spécialités confondues) dans le camp de Goudébou soit une prévalence de 30,47 % au niveau du camp. Par jour nous recevions en moyenne 9,17 patients en consultation dermatologique dont certains venaient d’euxmêmes et d’autres étaient référés par nos collègues d’autres spécialités. Le sexe féminin a représenté 71 % (1 173 cas), le sexe masculin 29 % (479 cas) et les enfants, 42 % (304 cas). Parmi les dermatoses observées : les dermatoses infectieuses représentaient 603 cas (36,50 %), les dermatoses immuno-allergiques 192 cas (11,60 %) et les dermatoses inflammatoires chroniques 316 cas (19,10 %) et les dermatoses carentielles 387 cas (23,4 %).

2. HCR, État des lieux de la situation au Mali, numéro 14, 1er janvier 2013, voir http://www.unhcr.org/cgibin/texis/vtx/ search?page=&comid=4f79b7eb9&cid=49aea93ae2&scid= 49aea93a77&keywords=maliemergency. 3. Communiqué de presse du Conseil de sécurité sur le Mali, 11 décembre 2012, http://www.un.org/News/Press/docs//2012/ sc10851.doc.htm 4. ALBARES TENDERO MP1, BELINCHÓN ROMERO I, RAMOS RINCÓN JM, SÁNCHEZ PAYÁ J, COSTA AL, PÉREZ CRESPO M, SILVESTRE SALVADOR JF. Dermatoses in Latin American immigrants seen in a tertiary hospital. Eur J Dermatol. 2009 Mar-Apr; 19 (2) : 157-62. doi : 10.1684/ejd.2008.0600. Epub 2008 Dec 23. 5. Michael S. STEVENS, BScPT, MD1, Jennifer GEDULD, MSc2, Michael LIBMAN et al. Dermatoses among returned Canadian travellers and immigrants : surveillance report based on CanTravNet data, 2009 – 2012 CMAJ ISSN 22910026; 6. ALBARES MP1, BELINCHÓN I, RAMOS JM, SÁNCHEZ-PAYÁ J, BETLLOCH I. Epidemiologic study of skin diseases among immigrants in Alicante, Spain Actas Dermosifiliogr . 2012 Apr; 103 (3) : 214-22. doi : 10.1016/j.ad.2011.07.008. Epub 2011 Sep 13.

Conclusion : la fréquence élevée des dermatoses chez

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Continuing Medical Relief Operations in a Military Medical Facility Compromised by a Flood Disaster: Lessons of Kashmir Floods 2014.* By L. NS∑ and P. SK∏. India

Lamba NS Major General NS Lamba is Deputy Commandant & Dean, Army Hospital (R&R) in Delhi, India. QUALIFICATIONS: MBBS (Armed Forces Medical College, University of Pune 1982). MD (Anaesthesia) (Armed Forces Medical College, University of Pune 1990). PDCC (Neuro-Anaesthesia) (All India Institute of Medical Sciences, New Delhi- 2001). EXPERIENCE HOD & Professor Anaesthesia : AHRR, New Delhi 2011-2013. Commandant 92 Base Hospital : 15 Corps-2013-2015. Consultant & HOD Anaesthesia CH (WC) : 2015-2016. A WARDS Dr Ambedekar Award : Pune University (1st in MD 1990). COAS Commendation : 2000, 2012, 2015 and 2016. Army Commanders Commendation : 2006. BSF Commendation Roll : 2015.

RESUME Maintien des opérations médicales de secours dans un hôpital militaire affecté par des inondations. Leçons tirées des inondations du Cachemire en 2014. Contexte : les Inondations du Cachemire de 2014 furent l’occasion de montrer ce que pouvait être le soutien médical dans un contexte d’inondations urbaines et dans un hôpital de référence de l’armée indienne partiellement inondé lui-même, qui plus est dans une région de contre-insurrection. Obj ectif : Présenter les activités de l’hôpital 92 de Srinagar du 7 au 24 septembre 2014. Résultats : Sont présentés : la conduite opérationnelle des secours à la population locale, l’effondrement presque total du système civil du fait de l’inondation, les difficultés de transports, la prédominance des cas pédiatriques et de médecine néonatale, les défis dans le commandement et la logistique des secours. Nous avons traité une moyenne de plus de 570 cas par j our avec une mortalité globale de 5, 7 %. Conclusions : Dans les régions susceptibles d’être affectées par des grandes inondations, il est nécessaire de p rendre en mains les plans d’organisation, de formation, les app rovisionnements, les équipements et les communications. Ces éléments sensibles dans les situations de catastrophes en temps de paix doivent être mis en œuvre de façon à la fois énergique souple et efficace pour apporter des soins d’urgence de masse à des populations d’âges divers. Les conséquences sanitaires sont variables en fonction de contextes géographiques différents et il est nécessaire d’en étudier les conséquences à long terme tant dans une optique générale que plus spécifiquement militaire.

KEYWORDS: Flood Relief, Military Medicine, Medical Aid, Child. MOTS -CLÉS : Secours en cas d’inondations, Médecine militaire, Soutien médical, Enfant.

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Climate change related water disasters (CCRWDs) are natural geohydrological extreme weather events such as floods and storms. They have devastating impact on the health of vulnerable communities owing to their

INTRODUCTION Climate change and variability are considered some of the biggest threats to human health in the 21st century.

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METHODS

unpredictability and magnitude1, 2. Amongst the CCRWDs, floods are the most common type of disaster globally and are the main cause of disaster related deaths across the world responsible for more than 500 deaths annually3 . Most flood-related deaths are attributed to flash floods3, 4, 5. Flash floods by their very definition often do not give adequate response time to a population. In last 15 years, there have been 5 major flash flooding events in Indian history: Odisha 2001, Mumbai 2005, Leh 2010, Uttarakhand 2013 and Kashmir 2014 apart from the devastation from other CCRWDs like Odisha Cyclone 1999 and the Tsunami in 20044, 6, 7 .

This is a descriptive study of the events in September 2014 at AFMF around the time of the flood event with both quantitative as well as qualitative approach based on first hand participant narratives of the authors, interviews and informal discussions with the responders as well as the treated population and a retrospective analysis of the processes and documentation of the logistics and medical records during the crisis.

RESULTS Meteorological Data (Fig. 1)

Coordinated, well-planned management of health interventions must be taken for timely action in the response, recovery, prevention and preparedness phases of disasters8 . Military forces all over the world play an important role in provision of medical and non medical humanitarian relief during natural as well as manmade calamities. In absence of a prior risk assessment and preparedness for disaster in a geographical region, and especially with no precedent event in past, a coordinated and effective mitigation of the ill-effects by civilian authorities alone may become limiting7, 9 . Historically in face of a civilian administrative collapse, world over military services are requisitioned to get involved in the relief operations4, 9, 10, 11. This has been observed frequently in India too in relation to CCRWDS as well as other disasters4, 6, 9, 10, 11.

Normally, rains take place in J&K from July to midSeptember. Unprecedented rains were caused by the interaction of the westward moving monsoon low pressure area across central and northwest India and a eastward-moving deep trough in the mid-tropospheric westerlies. The additional low pressure areas that formed over Saurashtra and Kutch on 3 September 2014 and over head Bay of Bengal on 5 September 2014, ensured the vigour of the event was maintained through strong wind and moisture flux in J&K. Numerical weather prediction models could capture heavy rains over J&K only in day 1 forecast and lack of adequate dissemination of weather warning further exacerbated the problem. The combined average temperature over global land and ocean surfaces for September 2014 was the highest on record for September, at 0.72°C (1.30°F) above the 20th century average of 15.0°C (59.0°F). In Srinagar during this month temperatures averaged between 22°C maximum to 13°C23 .

Jammu and Kashmir (J&K) faced unprecedented floods of the century in the first week of September which led to a large scale humanitarian relief effort of Indian Armed Forces named Mission Sahayata in face of a complete collapse of civil administrative machinery at the outset of the calamity7, 12 . Indian Army’s flood relief humanitarian assistance to civil authorities was named 'Operation MEGH RAHAT'13 . The Indian Army, Air Force, and the Navy, committed thousands of troops, multitude of engineer task forces, and numerous fixed wing transport aircraft and helicopters, naval commandos and rescue specialists alongside many medical establishments during this. While "Operation Megh Rahat ", ended on 19 September 2014, "Operation Sadbhavna ", the relief and medical assistance support, continued in close synergy with the civil administration and the police in the post flood phase 14 .

Floods resulted from breach of embankment and overflowing of the Jhelum river resulting from a high rainfall to the tune of 450mm over 3 days in the catchments since Sep 4, 2014, and diminished capacity of drainage system owing to disruption of the network of lakes and blockade from unplanned urbanization over past few years24 . On September 3 there was a rainfall deficit of 32 percent but on September 8 it showed excess of 18 percent i.e. a change of 50 percent in five days. But unfortunately no effective advance warning was provided by any concerned agencies for pre-emptive measures. By 6 September, massive flooding occurred and 2600 out of 6,651 villages were variously submerged in J&K. Of 104 urban areas and 8 urban agglomerations in the state, 30% were submerged. More than 300 villages

There are unique challenges inherent in maintenance of medical services amidst of floods when inundation of medical set-up compromises infrastructure, supplies and its own human capital15, 16, 17, 18, 19 . Further the rescue efforts themselves expose the personnel to health risks20 . Documentation of sentinel events and military medical relief efforts following heavy rainfall is scarce in published medical literature considering the frequency of such calamities and the historical involvement of military in relief efforts4, 6, 11, 21, 22 . We seek to elucidate the role of a premier armed forces medical hospital facility (AFMF) at Srinagar during the epic flood relief operations for the Kashmir floods in Sep 2014 to gather lessons in continuing medical relief operations in a military medical facility itself compromised by a flood disaster.

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∑ Major General, Deputy Commandant and Dean. ∏ Group Captain, HOD & Senior Advisor Pediatrics. Correspondence: Group Captain SK Patnaik HOD & Senior Advisor Pediatrics, Army Hospital Research and Referral, Delhi Cantonment - 10 IND-11010 New Delhi, India Mobile number: +91-8527917111 Email: drskp@yahoo.com * Presented at the 42nd ICMM World Congress on Military Medicine, New Delhi, India, 19-24 November 2017.

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Figure 1: Weather Conditions f rom 02 to 08 Sep tember 2014 with aerial shot of f looded areas in Kashmir Valley.

Overview of AFMF

were completely cutoff and in urban areas water levels crossed 20 feet7 . The floods worsened over the next few days due to incessant rains and overflowing flood channels and by month end had taken the lives of 300 people. In all, 557 sq km area was inundated. Out of this 444 sq km was agriculture land, 20 sq km horticulture land, 67 sq km built up area, 3 sq km forest area, 21 sq km wasteland and 2 sq km others. An approximate population of 22 lakh was affected covering 287 villages.

The AFMF is a large multi disciplinary hospital with all basic specialties catering to hundreds of patients at any time across dozens of inpatient wards and OPDs and can expand in event of crisis. The upper level houses the administrative complex, intensive care unit (ICU), Laboratory, part of Radiology (MRI and Ultrasound), operation theatres (OTs), helipad, casualty and triage room apart from few wards, part of medical stores and oxygen plant and adjoins the residential areas. The lower level part of the hospital across a road houses the X Ray and Computed Tomography (CT) Scan Centre, Medical stores, Accident & Emergency (A&E), Polyclinic, Dental facility and medical documentation.. Residential areas are contiguous at that same level. Overall 1/3rd each of the beds are with medical and surgical specialities while ICU beds comprised 4% and the pediatric beds comprised 2%.

Geographical Assessment In Relation To Medical Facilities (Fig. 2)

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Many parts of Srinagar were inundated, and vital roads were submerged, by the floods owing to their proximity of the Jhelum river. Amongst the 6 major civilian medical facilities in the city of Srinagar (Government Medical College, Shri Maharaja Ha ri Singh hospital, Bone and Joint hospital, SKIMS Medical College, Bemina Tertiary care Lalla Ded Maternity Hospital, and the GB Pant Cantonment General Children’s Hospital), 4 were severely inundated and had to be shutdown by 6 Sep 2014 7 . The GB Pant Cantonment General Children’s Hospital (GBPCH) is the lone pediatric hospital for the entire Kashmir valley, and is located adjacent to the cantonment area which houses various administrative and medical echelons including the AFMF. A large proportion of the cantonment area including the military hospital was inundated except for the zones located higher up2 . Other armed forces medical facilities in Srinagar including field hospitals of Army and those with Air Force have limited inpatient holding capacity.

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Flood Disaster Response at AFMF The deluge of rainfall started on by 1030 hours on 04 Sep 2014 and in the night of 06 Sep 2014 the lower level part of hospital had been submerged in the flash flood. (Fig . 2, 3, 4). The following steps were immediately carried out on 06 Sep 2014 as soon as the flooding was noted: a) Activation of disaster drill with recall of all staff. b) Establishment of a 24 hour emergency response control room. c) Rescue of Med Store Supplies, Arms & Ammunition and Vital Documents from inundated areas by a human chain of hospital staff. (Fig. 3).

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Figure 2: Map of Flooded areas in Sep 2014 . Anticlockwise f rom top lef t: Schematic map of f looded areas in Jammu & Kashmir during Sep 2014; Extensive f looding of Srinagar and adj oining areas (dep icted in shades of blue-p urp le) and the winding course of river Jhelum (deep indigo); all government medical f acilities were in the f looded areas; Satellite shot of the partially f looded armed f orces medical f acility.

Figure 3: Images of inundated areas of hosp ital and rescue of medical stores on 07 Sep 2014; relief team reaching out to a houseboat.

with 24 hour manning by medical officers, nursing officers and paramedical staff. Every case arriving here was assessed and either detained or admitted as per necessity. h) Activation of pre-designated medical teams with designated leaders for patient evacuation as well as conduct of medical relief camps for civilian populations trapped in flood waters in various parts of Srinagar. i) Strengthening of perimeter defence with additional security pickets with help of adjoining units and hospital staff. j) Rescue and evacuation of families of hospital staff (doctors, nurses and paramedics) from flood inundated areas. k) Arrangement of alternate accommodation on sharing basis for personnel whose houses were inundated. This included 15 doctors and nursing officers themselves. l) Rationing and securing of water and food supply m) Electrical power supply to vital areas like ICU and OT was ensured through gen sets. n) For other less vital areas including living quarters power supply was limited by diesel gen sets. o) Emergent indent demands were placed for medical stores especially antibiotics, water purification kits and warm clothing and blankets. p) Community messing facility established. q) Hospital central laundry resumed its function within 3 days.

Mass Evacuation from the GB Pant Children’s Hospital (Fig. 5)

Figure 4: Images of inundated residential areas and grounds in vicinity of the hosp ital.

The children’s hospital, a multi-storeyed facility was caught in the sudden deluge and was submerged up to 20 feet of water. This hospital caters to the entire J&K with a focus on neonatal cases. With inundation of the neonatal and pediatric ICUs, the surviving inpatient children along with a team of doctors from the GBPCH were evacuated by rescue team of army starting the night of 7 Sep 2014 by boats to the AFMF. Over the subsequent days, the latter formed a nodal medical facility for these children and adults brought in from other parts of the Kashmir valley by their caregivers and medical rescue teams of Army till the civilian medical facilities could resume their function. (Fig. 5, 6). Figure 5: The GB Pant Childrens hosp ital on 08 Sep 2014 and the rescue eff ort ongoing.

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d) Inspection and securing of mechanical transport including ambulances. e) Prevention of further damage to CT Scan by power disconnection by the radiology technicians and the military engineering service representatives. f) The accident and emergency department was reestablished at a higher level by conversion of the hospital auditorium. g) Separate Reception & Triage areas were established

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Figure 6: Expansion beds inside the p ediatric ward comp lex .

With the additional load the following actions were executed: a) Reinforcement of medical personnel and stores from area of command as well as with request to other services (Air Force and Navy). This included an additional medical specialist, 1 general pediatrician, 1 pediatric nephrologist, 1 anesthesiologist, 1 ENT specialist and 2 General Duty Medical Officers. b) Expansion of crisis beds in the family ward complex in the pediatric ward and allocation of beds in the adult ICU for pediatric and neonatal cases. c) Central manifold and oxygen supply plant were kept activated. d) Adequate supply of hand sanitizers was maintained to ensure asepsis especially in face of water shortages. e) Local EME workshop mechanics were co-opted to keep equipment running especially radiant warmers. f) Necessary outward transf er of cases from AFMF was arranged by army aviation and IAF helicopters. Over subsequent 2 weeks, apart from the pediatric load from GBPCH, flood victims from Anantnag in Southern Kashmir were also air evacuated to AFMF and managed here. A total of 72 pediatric cases were evacuated from GBPCH in the night of 07 Sep 2014 and the rest followed subsequently till 12 Sep 2014. As per media reports at least 14 children got trapped and could not be rescued. Amongst the rescued babies on the first night, there were 6 infants in incubators between 4-17 days age and 7 children were brought in dead. A batch of 6 cases were flown in from Anantnag on 15 Sep 2014 apart from the routine OPD and post-natal care for babies in the hospital. Till 10 Sep 14, the team of resident pediatrician doctors from GBPCH augmented the lone pediatrician at AFMF who was joined in by 2 more pediatricians flown in by 11 Sep 14. The remnant rescued team of doctors from GBPCH left on 12 Sep 14 as waters started receding to contact their own families. All medical officers posted here irrespective of their speciality joined in to handle the initial deluge of cases carried in boats to the MI room, crisis ward and pediatric ward complex. The remaining 2 pediatricians continued the efforts after 16 Sep following the departure of the posted pediatrician on casual leave till 28 Sep 2014. By end September the augmentation across specialities ceased and AFMF slowly reverted back to its routine work.

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Post Disaster Activities Repair and rehabilitation of the assets inundated at the lower level was gradually carried out (Fig. 7 & 8). By the 3rd week the hospital polyclinic had started functioning again and the medical stores had been segregated, dried and necessary retrievals made. The CT Scanner was damaged beyond repair. A ug mentation of medical stores and relief supplies were flown in and were received by end of 2nd week. Communication was maintained through satellite receivers and appropriate sensitive handling of media and official visitors was handled by the hospital chief and his team. A damage assessment at end of the floods revealed no loss of life to any of the personnel but irreversible loss of material belongings and housing for 15 doctors and nursing officers of the hospital apart from the loss of stores and infrastructure. Figure 7: Recovery of medical stores and p olyclinic areas af ter water started receding .

Figure 8: Af ter the f lood waters receded in the hosp ital and its vicinity.

Morbidity Profile of Cases By 24 September 2014, a total of 8235 patients had been treated by the medical relief teams and 1625 civilians had been seen in the OPD at the AFMF of which 237 (15%) were admitted and treated for variety of ailments. Over a period of 2 weeks, 158 pediatric cases were received and treated at AFMF. The spectrum of pediatric cases encountered ranged from various neonatal conditions especially sepsis and meningitis and respiratory distress to older children with seizures, pneumonia and encephalitis. Majority (49%) were neonates (28-42 weeks, 1.3-3.4kg) and young

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infants. Neonatal sepsis (24%), pneumonia (15.5%), meningoencephalitis (13%) and RDS (9.5%) were commonest. A total of 4 babies managed at AFMF were transferred out to SKIMS after a fortnight after it resumed functioning - one neonate with cyanotic congenital heart disease with primary pulmonary hypertension, one 1.5kg 34 weeks old neonate who underwent Double Volume Exchange Transfusion and was detected to have ileal atresia, one child with acute hepatic encephalopathy and one child with chronic lung disease with ventilator dependence. ICU care occurred for 32. Overall 16 babies were managed in the adult ICU and 16 babies needed neonatal intensive care support during this period of 18 days. Overall mortality was 5.7%. Of the total of 9 deaths amongst the kids handled during this period, only one wa s related to an Armed Forces personnel - neonate of a serving personnel admitted at GBPCH who expired on 09 Sep 2014. Three babies with severe neonatal sepsis were brought in terminal state on manual ETT-IPPV on the day of evacuation from GBPCH and expired on 08 Sep 2014.

for the superimposed medical relief role is elucidated below in Table 1. From the start of Mission Sahayata till 16 September, the Armed Forces rescued 2,37,000 persons, and airlifted and distributed 2,24,000 litres of water, 31,500 food packets and ready to eat meals, 375 tonne cooked food, 2.6 tonne of biscuit, 7 tonnes baby food, water purifying tablets, 8,200 blankets, 650 tents, to the affected civilian population. The logistic challenges encountered were enlisted in Table 2.

DISCUSSION Floods are the most common type of disaster globally, responsible for more than 500 deaths annually in the last decade alone (23: 1 low- versus high-income countries) 25, 26. Long-term effects are currently not well understood and mortality rates were found to increase by up to 50% in the first year post-flood25. An increased risk of disease outbreaks such as hepatitis E, gastrointestinal disease and leptospirosis, particularly in areas with poor hygiene and displaced populations is documented26. Psychological distress in survivors (prevalence 8.6% to 53% two years post-flood) can also exacerbate their physical illness25, 26, 27. A need for effective policies to reduce and prevent flood-related morbidity and mortality as well as a seamless disaster management plan for armed forces troops serving in flood prone areas is contingent upon the improved understanding of potential health impacts of floods27, 28.

Amongst the ICU admissions, 6 babies died overall. Majority of the latter were a sequela of encephalitis. From 11 Sep till 27 Sep a total of 9 babies were ventilated for a net of 32 days in toto with 22 intubations. A total of 6 central line insertions were carried out in this period - notable being a 16 day old with subclavian and a 2 month old with IJV access. Phototherapy was exhibited to 15 babies during this period - 2 babies underwent double volume exchange transfusion during this period. During this period the routine hospital OPDs for the armed forces personnel and their families continued as usual with skeletal staff. Elective surgeries were postponed. Deliveries and cesarean sections continued including for civilian flood affected victims. During and in the aftermath of the disaster there was no epidemic of communicable diseases and no surge of mortality noted at AFMF.

The process of human response to natural disasters and its mechanisms as revealed by an analysis of a historical chronicle has a broad significance for all societies more so the armed forces26, 27, 29. Chronicling of the precise role of military during peacetime medical relief for civilian populations is often underplayed by the civilian authorities due to concerns about credit sharing as well as by a penchant by militaries for official operational secrecy9, 10, 11. The unique disciplined selfless ethos and systematic approach of military systems has vital lessons for civilian policy makers for disaster management amidst natural calamities which sadly are known to recur4, 6, 10, 11.

Assessment of operational and logistic assets and limitations

The state of J&K has been ravaged by militancy over past few decades and the military is deployed in active

The strengths and weaknesses of the medical facility

Table 1: Assessment of Operational Parameters for Disaster Medical Relief.

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STRENGTH

WEAKNESS

• Major Hospital assets were safe. • No significant attrition of manpower.

• A&E, OPD complex CT scan and portion of medical stores affected.

• CI Ops Hospital: trained for emergency role.

• 15 members of the faculty affected.

• Strong hospital infrastructure.

• Neonatal/ Paediatric pt load.

• Overwhelming logistic support from the formation HQs & medical echelons.

• No road/air link X 24h. • No Mobile communication.

• Well trained motivated manpower.

• No electricity x 7days.

• Favorable temperatures without any cold stress typical of severe winters in the valley.

• Limited water supply.

• Minimal adult casualties.

• Limited medical stores.

• No civil manpower. • Limited Rations/FOL.

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responders29. The AFMF staff were adequately prepared courtesy their continued systematic military training amidst the medical duties for a person in uniform. Climate can be harsh limiting factor especially heat related injuries in sandbagging operations30. The ambient temperature in Srinagar during this period prevented occurrence of these and since the harsh winter had not yet set in cold injuries too were not a limitation for the troops involved.

Table 2: Logistic Challenges during the Disaster Medical Relief. Multiple agencies. Multiple supply points. Supply point access/Transportation. Multiple supply inventories. Demand: Supply mismatch. Relief material distribution. To late and often too much. Catering for VIPs and Media.

Health leadership in a disaster needs an approach similar to that of professions such as law enforcement, military and freighting31. Institutional leaders amongst various responders may struggle to apply the disaster plans in the face of spontaneous disaster leadership from amongst local masses as was observed even during these floods amongst the local Kashmiri population32. Both the recognized leadership of an organization, and those who in a disaster may step up as disaster leaders need to be confident in implementing the disaster contingency plans. This complex interplay between the medical and nonmedical military echelons as well as civilian administrative and medical authorities was noted during Srinagar floods too. Medical outreach camps from AFMF were effective in reaching out to needy stranded populace with medications and succour.

counterinsurgency operations out there since independence and does face a hostile local environment of Kashmir Valley. The medical relief operation was not just limited to AFMF but extended across the valley with many field hospitals mobilized in a very short span of time 12, 13, 14. We focus on AFMF, a tertiary care facility, since it was the evacuation node for all lower formation medical units. Further apart from the SKIMS Srinagar, it was the only fully functioning hospital in the Kashmir Valley throughout the initial period of deluge till 14 Sep 2014. All the medical relief from civilian authorities and NGOs truly became available to the masses only after this period 14. This facility itself was inundated in part and bore a brunt of pediatric mass casualties which is unique to the adult orientation of medical aid of Armed Forces. The epic tragedy and review of the role of AFMF in the medical relief operations in a hostile environment reinforces previous observations that global trends in urbanization, burden of disease, local context and maternal and child health must be better reflected in flood preparedness and mitigation programs for armed forces too as for civilians 11. Efforts to reduce morbidity and mortality from a disaster should precede it for an optimal outcome1, 8, 11. These include development of an organization to reduce the impact of disaster, training of medical personnel in techniques of rescue and in treatment of victims in disaster areas; development of a plan to assist the leadership in decision-making and establishing support for disaster preparedness; and maintaining sufficient capacity in general hospitals for the admission of victims from disaster areas1, 8, 11, 15, 16, 17. The emergency response of AFMF fulfilled most of the criteria for an optimal outcome. The military training of the armed forces medical corps personnel ensured a swift adaptation to increased demands in the moment of crisis and an effective use of scarce resources could be ensured even as the military personnel too were caught unawares by the sudden floods.

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Inability to predict the occurrence as well as the impact of floods, damaged routes, loss of health workers and health infrastructure including essential drugs and supplies, lack of sanitary appliances and clean drinking water, sickness, stress, continuing bad weather with risk of aggravation of flooding, offensive smell surrounding stagnant water, disrupted electricity services apart from secondary stressors from loss of livelihood, limb and material possessions affect not just the victims of flood but also the healthcare teams27, 28. Flood relief operations can be physically daunting for emergency

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Effective human resource management is essential to ensure adequate staff capacity and the continuity of operations during any incident that increases the demand for human resources4, 6, 8, 29. Leadership in disasters must have a clear distinction between incident controller and 'clinical leader' roles31, 33. A well-functioning command-and-control system ensured vital and effective hospital emergency management leadership under the chief of the AFMF. Operational efficiency was maintained with the medical, nursing and nonmedical administrative echelons of the hospital ensuring a 24x7 unbroken logistic chain of medical and non medical supplies and continuation of hospital services. Administrative support and motivational blameless leadership style of the chief of the hospital along with an empathetic approach provided a safe and motivating environment for health-care workers to discharge their duties to their utmost satisfaction. Disasters may result in a large volume of responders arriving on-scene to provide assistance to victims and coordination of responding resources is a major problem in disasters and needs optimal resource deployment and dispatching 33, 34. This was undertaken by the higher administrative authorities at formation headquarters. AFMF was rendered functionally independent to provide the clinical care which it was meant to do well. The nature and history of the region of flood disaster limited access of responders in the initial phase which was a blessing in disguise too. The emergency response services including National Disaster Relief Force personnel came into the picture later and gradually took care of the civil ian population in tandem with the Indian Armed Forces till the local administration could be rejuvenated 32.

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Boats over the roads of Srinagar became the primary mode of transport for medical teams. The impact of the floods on transportation routes for men and materials can be gauged from the fact that a distance of 10km from Srinagar Airport needed a botaride or a helidrop followed by a road travel of at least 1-2km to reach AFMF during the floods since the helipad at AFMF itself was submerged. An initial shortage of relief material owing to difficulty in transporting material due to bad weather and closure of the Jammu Srinagar Highway and limitations on air operations32. By the time the material arrived it was in surplus and could replenish the critical hospital stores which had been used for civilian patients.

absence of a sound military leadership. In spite of handling the deluge of civilian cases, the primary role of AFMF to cater to armed forces personnel and their families remained sacrosanct and the normal functioning of the hospital OPDs and in-patient services carried on. The administrative leadership and the self motivation and extra efforts of the staff both were vital as has been noted previously in such disaster relief operations involving Armed Forces4, 6, 11. All staff doctors chose to stay back after sending off their families and nursing staff too carried on with their assigned duties without any complaints. Overall a well-coordinated implementation of hospital operations at every level was ensured.

Clear, accurate and timely internal and external communication is necessary to ensure informed decisionmaking, effective collaboration and cooperation, and public awareness and trust1, 7, 8, 34, 35. Unambiguous communication of roles and responsibilities of each member of team as well as a 24 hour feedback loop with higher formations and civilian medical authorities ensured cooperation and a productive teamwork4, 6, 11, 35. This in turn ensured there were no conflicts or complaints from the accompanying attendants. While there has been an advocacy for continued development of health information Web sites and other technological alternatives in modern time, useful and effective public health communication through channels such as television, radio, or newspapers, may result in useful, inexpensive and effective health communication in similar situations35. In face of collapse of telephone and mobile communication networks, satellite based navigation systems were used to communicate. This was a means for the armed personnel and their families to be in touch and free of worry.

This disaster exemplifies the need for flexibility of any disaster management plan - populations with special medical needs not only must become part of any response design but the effects that any response activity may have on the community as a whole should be carefully considered before action is taken11, 27, 28, 33, 34, 36. Service delivery especially surgical operations and referral systems are very vital for favorable outcomes, but are not always available during the storm and flood seasons in many remote geographical regions. AFMF has a well equipped in-house surgical team including a vascular surgeon to handle all emergencies. The crisis expansion beds and ordnance stores provided a surge capacity to expand the scope of health service beyond normal to meet increased demand for clinical care. This hospital located in a counterinsurgency area, is acknowledged for its expertise in trauma care yet it was not designed for a pediatric mass disaster. A vital lesson previously noted during flood crisis was that we must continuously reassess to assure the best utilization of resources in rapidly changing conditions, cater for cross-training in the content of emergency plans at all levels across age spectrum, and must have a non-going face-to-face liaison among response managers to improve the response efforts34.

Well-developed safety and security procedures are essential for the maintenance of hospital functions and for incident response operations during a disaster especially in a counterinsurgency operations area with breached perimeter walls due to the floods. This was ensured by the hospital staff, use of well patients admitted with the hospital and by manpower from units located adjacent to the hospital. Crowd control and security of hospital assets was an important consideration during these times which did stress the thinly manned staff in pediatric complex at AFMF during peak days of the crisis.

During this crisis, AFMF alone was handling ~ 750 cases per day through its in-hospital OPDs and outreach medical teams in boats in addition to the routine though attenuated daily inpatient load. About 15% of these cases were hospitalized between 7-24 Sep 2014. A total of 158 critically ill neonates and young children were admitted at AFMF during this phase. The criticality and age spectrum of the cases is very different from the previously recorded relief efforts of armed forces. As a comparator, it is worth noting that during a similar flood crisis in Houston, a 25-bedded Air Force expeditionary medical support unit handled approximately 95 patients per day22. During the 2001 Orissa floods, a single Indian Army medical team handled ~827 cases per day in on-site medical aid posts in flood affected areas over 9 days comprising predominantly of gastrointestinal illnesses (54.2%), respiratory infections (27%) and injuries (13.1%)6. During the Uttarakhand flooding, majority 44.4% of 234 deaths were 25-50 years4. While a review of Indian army relief efforts in Nepal earthquake in 2015 noted a case load of ~251 cases per day over 1 month handled through 3 medical teams of which 1/5th were children and adolescents11.

A disaster does not remove the day-to-day requirement for essential medical and surgical services that exists under normal circumstances. Continuity of essential services must be maintained even during a disaster scenario in parallel with the activation of a hospital emergency response plan and the same was successfully implemented1, 33, 34. It was imperative for the military leadership that in the medical aid response for the civilians, the needs of the members of the military community which itself was devastated materially and psychologically by the same floods, was also catered for6, 11. While being duty-bound to sacrifice for others, unless the latter was catered for especially for the families, morale and performance of troops could be compromised in

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The shift of role from a predominant adult clientele to neonatal and pediatric critical care mandated by this flood crisis could be accomplished successfully by various measures. In this disaster mitigation role, though only 1 pediatrician and pediatric matron each were posted in this hospital and only 2% of hospital beds were originally allocated to children, the pediatric ward with its space could easily expand into crisis bed zone (Fig. 6). Apart from an existing makeshift NICU with 2 radiant warmers and 1 CPAP machine, with more number of cases needing critical care and oxygen supply, the adult ICU served to augment our ability to handle the deluge of pediatric cases. The ICU ventilators and beds with appropriate heating appliances could augment capability to handle critical neonatal and pediatric cases. Exchange transfusion for premature neonates with neonatal hyperbilirubinemia could be performed in the OT during this crisis even in the absence of adequate power resources for intensive phototherapy. In peacetime scenario the neonate would have been transferred to another facility with neonatologist.

flood disaster scenario with high anticipated load of drowning, respiratory, gastrointestinal and infective disorders. With limited available nursing time, a less than excellent skill could vitiate the potential outcomes. It is well known that during floods, the primary cause of flood-related mortality is drowning. In developed countries, being in a motor-vehicle and male gender are associated with increased mortality, whereas female gender and children are more vulnerable in the aftermath disorders 26, 28, 36, 37. When the flood waters rose during the night of 6th September, most of the people were asleep in their homes in the Cantonment area but guard pickets could detect the flooding early and with adequate warning people could climb up to higher floors till they were rescued later in the day. Drowning incidents were minimized amongst the hospital staff accordingly. However majority of the inpatient children in GBPCH, where the NI CU and PICU were located in the first 2 floors and were fully submerged, suffered effects of hypothermia and submersion injuries especially those who could not be disconnected immediately from the machinery in face of gushing flood waters 32.

Logistics and supply management were daunting during this crisis. Continuity of the hospital supply and delivery chain, an underestimated challenge during a disaster, was ensured by attentive contingency planning and response. A proactive clear cut communication from the ICU in charge of the hospital for augmentation of supplies for pediatrics in form of vascular access, oxygen cannulas, ETT etc. in the night prior to departure of one of the authors (SKP) ensured that the pediatric team was forewarn ed, well stocked and prepared to handle critical cases.

Risk of infectious diseases after weather or flood-related natural disasters is often specific to the event itself. It is dependent on a number of factors, including the endemicity of specific pathogens in the affected region before the disaster, type of disaster itself, impact of the disaster on local water and sanitation systems, availability of shelter at a high ground, congregating of displaced persons, functionality of surviving public health infrastructure, availability of healthcare services, and the rapidity, extent, and sustainability of the response after the disaster. Weather events and floods impact disease vectors and animal hosts in a complex system38. Most of in-hospital mortalities during this period in our experience were not related to drowning injuries but due to encephalitis. Overall the association of flooding with infectious disease remains a controversial issue38, 39, 40.

Interestingly during this period there were not many adult patients needing ICU support. This fortuitous coincidence ensured that the crisis could be managed reasonably well within the available resources. In an alternate scenario with many adults demanding ICU care, without adequate ventilation facilities, piped oxygen support and monitors, the outcomes may not be as fortunate if the critical cases had to be managed only in the limited NICU and pediatric complex. The experience remains invaluable for planning and handling this vulnerable section of population even in setups with adult physicians and adult oriented ICUs in geographical zones known to be afflicted with CCWRDs. Further the utility of training all personnel in pediatric basic and advanced life support as well as neonatal resuscitation protocols was evident in this crisis since natural disasters do not spare any age and women and children remain the most vulnerable group!

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Unlike primary care with one time contact with the treating team, with cases admitted to the hospital with previous multiple caregivers, hospital associated infections are a major challenge to be addressed40. Majority of children from the civil hospital were already exhibited to multiple antibiotics and details were often illegible which challenged adherence to a rational antibiotic policy of the armed forces set-up. Increasing antibiotic resistance of our hospital ICU and colonization of equipment from extramural multidrug resistant flora imported with the critical cases from outside was worry. Maintenance of asepsis especially in neonates and timely feeding with severely constrained nursing staff was another vexing issue. Handwashing protocols got compromised with limited water supply but liberal usage of alcoholic handrub solutions prevented infections. Parents especially fathers of the children were actively involved in feeding of the babies unlike peacetime family wards where they are usually not involved.

For an optimal handling of the predominantly pediatric specific morbidity profile of cases encountered during the floods, the lone pediatrician posted there with less than a years experience in the speciality at the time of this crisis, was augmented with a more experienced team from tertiary care armed forces hospitals in Delhi. Clinical experience and skills in vascular access and ventilation of the augmenting pediatric teams including pediatric trained nurses are vital in a

International Review of the Armed Forces Medical Services

Delineation of primary care giver roles and documentation of clinical case details during the deluge is vital.

Revue Internationale des Services de SantĂŠ des Forces ArmĂŠes

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by AFMF however remain outside the scope of this article. Chemical and biological contamination of flood inundated housing and its long-term consequences are well documented41. Issues pertaining to this for both the victims of the flood as well as the affected staff of any such facility involved in the medical aid efforts are areas of future investigation.

In the initial deluge of cases between 07-10 Sep 2014, it was a challenge for the nursing staff to adhere to a particular treatment protocol - local pediatrician from GBPCH accompanying the child versus the posted service pediatrician at AFMF. The same was subsequently resolved with the senior pediatrician augmenting the AFMF taking over primary responsibility for the decision making and documentation of all cases in view of a vicarious responsibility of the institution. Ensuring proper identification badges is vital to avoid any medication error in view of a similarity of names between various patients with common prefix (e.g. Mohammed). Further the volumes necessitated a switch from extensive detailed case sheets typical of military services to a focused problem oriented one prevalent in civilian practice. Compulsory brief but very specific documentation of the daily clinical state of each flood victim especially in a non digital scenario was challenging. Nursing officer reports were very meticulous and helpful in evaluating the clinical data retrospectively. We would strongly advocate the designation as well as assumption of the role of primary caregiver by the service pediatrician specialist in these scenarios right at the outset of arrival of a victim into the hospital. In future it is important to move away from paper based data keeping to avoid duplication of efforts and better time management11. Post-disaster recovery planning should be performed at the beginning of the response activities and necessitates humanitarian logistics and an ongoing process of evaluation of the post-flood medium and long-term impact. Prompt implementation of recovery efforts can help mitigate a disaster’s long-term impact on hospital operations41. Since adequate inventory levels are critical given the high uncertainty of delivery lead times for relief supplies, a voluntary rationing of food, water and fuel supplies was imposed during the flood relief for all – officers as well as other ranks. At the onset of flooding, maximum effort was put to retrieve and shift medical and non medical stores at AFMF to non-flooded zones followed by stock taking. Demand analysis, inventory planning and control, regional coordination and synergy, in-kind donations management and collaboration amongst various agencies/organizations involved are vital considerations for policy makers for such crises 34.

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Ability of any community to respond effectively to disasters depends on the strength of its health and social infrastructure, and its overall developmental status36, 40. The innate strength of armed forces environment and the social milieu of the personnel ensures a robust psychosocial response. Long-term psychological consequences of floods are well known for the victims as well as the responders1, 25, 26, 27, 28, 40. The hospital psychiatrist was actively involved in counselling of troops and families especially those with inundation of their house and the trauma of associated economic losses which was later sought to be compensated by the government. No immediate posttraumatic stress disorder was noted during this phase. A long-term surveillance for PTSD was instituted by the psychiatrist at AFMF. Consequences on the civilian population treated

International Review of the Armed Forces Medical Services

Unlike the typical civil government emergency plans which focus largely on disaster response rather than prevention, our military plans already had a clearly defined role of primary versus referral healthcare with well laid out standard operating procedures (SOPs). A well-set coordination mechanism among different sectors and military and non-military organizations already existed. Being a self-sufficient system of medical stores, financial limitation for healthcare was not a constraint. The staff headquarters also had a competent team with a nephrologist at helm of affairs with preventive medicine specialists who could address disaster epidemiology and prevention of communicable diseases with vector control and vaccination programmes with the pediatric teams. Pre-existing system of reports and returns in the Army ensured real time updates of actual on ground situation of relevance for medical channels. Yet it is important to realize that even in face of adequate warning, preventive evacuation of a geographical area may be impossible and alternative strategies must be devised to handle a worst credible scenario of floods42. Identification of safe havens and shelter in place inside the potential flood zones need to be catered for any future recurrences. Wherever families are resident in a military station, since women and children are particularly vulnerable to the effects of natural disasters, long-term disaster risk reduction strategies must be maternal and child sensitive too11. This is a vital learning from the medical aid efforts of the Kashmir Floods. Finally the socioeconomic impact assessment of the military medical relief efforts is vital. Use of social and electronic media must be carefully charted by a close watch and a system of loop feedback by the various administrative and operational echelons. Ironically the usual inherent credo of putting service before self of a person in uniform on ample display during the Srinagar floods 2014 was drowned in a not necessarily unbiased media deluge and analysis7, 12, 13, 14, 32. Even if the media coverage of the role of Army in medical relief in Kashmir maybe influenced by extraneous reasons, the herculean efforts of the Indian Army in the Kashmir Valley in the face of a massive administrative collapse resulted in saving of so many lives and has been acknowledged. Visits of dignitaries and media during the hour of crisis, potentially disruptive of the medical aid activities, is vital for a positive message of recovery and psychological well being of afflicted people. These disruptions were minimized by a controlled access, designated public relations officer and following a principle of informed consent. To conclude, a clarion call for operational planning of medical aid and logistic requirement for a recurrence of

Revue Internationale des Services de Santé des Forces Armées

this CCRWD scenario was provided to the AFMF especially since the local hydro geography of Jhelum and unplanned urbanization of Srinagar cannot be altered in future. A flood scare has already been repeated in April 2017. While limited numbers of critically sick adults could ensure allocation of resources for sick children and ensured survival in majority in 2014, the same may not be true in a future crisis. A well orchestrated disaster plan right at the outset of the crisis, clear delineation of roles from command and control to curative and preventive measures are vital in future for all military hospitals in geographical zones predisposed to CCRWDs. This would lead to better optimization of resources and outcomes in a similar future disaster scenario. There is a need to prospectively study the long term psychosocial and medical outcomes of CCWRD on the military personnel and their families as well as the civilian populations surviving these sentinel events. Maternal and child health must be integral part of medical flood preparedness and mitigation programs in future for military planning too.

12. VEENEMA TG, THORNTON CP, LAVIN RP, BENDER AK, SEAL S, CORLEY A. Climate Change-Related Water Disasters' Impact on Population Health. J Nurs Scholarsh. 2017 Nov; 49 (6): 625-634. 13. FRENCH J, ING R, VON ALLMEN S, WOOD R. Mortality from flash floods: a review of national weather service reports, 1969-81. Public Health Rep. 1983 Nov-Dec; 98 (6): 584-8. 14. GUPTA P, KHANNA A, MAJUMDAR S. Disaster management in flash floods in leh (ladakh): a case study. Indian J Community Med. 2012 Jul; 37 (3): 185-90. 15. STAES C, ORENGO JC, MALILAY J, RULLÁN J, NOJI E. Deaths due to flash floods in Puerto Rico, January 1992: implications for prevention. Int J Epidemiol. 1994 Oct; 23 (5): 968-75. 16. CARIAPPA MP, KHANDURI P. Health Emergencies in Large Populations: The Orissa Experience. Med J Armed Forces India. 2003 Oct; 59 (4): 286-9. 17. TABISH SA, NABIL S. Epic Tragedy: Jammu & Kashmir Floods: A Clarion Call. Emerg Med (Los Angel) 2015; 5: 233.

SUMMARY Background: Kashmir floods of September 2014 provide an unique window into medical aid in urban flooding scenario in a partially inundated military referral facility of Indian Army in a counterinsurgency zone.

18. STEIN JJ. Medical preparedness for disaster. Calif Med. 1959 May; 90 (5): 353-5. 19. MARIASELVAM S, GOPICHANDRAN V. The Chennai floods of 2015: urgent need for ethical disaster management guidelines. Indian J Med Ethics. 2016 Apr-Jun; 1 (2): 91-5.

Objective: To document medical aid efforts at 92 Base Hospital Srinagar between 7-24 Sep 2014.

10. RAJAGOPAL G, SINGH KK, ANAND AC, RAI KM, JAYARAM J. Ex-Servicemen Medical Aid Group (ESMAG): The Hidden Force. Med J Armed Forces India. 2008 Jan; 64 (1): 61-4.

Results: Operational conduct of medical relief for local population, near complete shutdown of civilian medical machinery due to floodwater inundation, limited transportation, predominant neonatal and pediatric cases, challenging command and logistics issues of medical relief effort were observed. More than 750 cases were seen daily with an overall 5.7% mortality.

11. CHAUHAN A, CHOPRA BK. Deployment of Medical Relief Teams of the Indian Army in the Aftermath of the Nepal Earthquake: Lessons Learned. Disaster Med Public Health Prep. 2017 Jun; 11 (3): 394-398.

Conclusion: Organized plans entailing training, supplies, equipment and communications for use in major peacetime disasters in areas likely to be flooded should be carried forward vigorously with flexibility and ability to provide mass emergency care across various age groups. Health impacts of a particular flood are specific to the particular context and multidimensional long-term outcome studies are needed from military perspectives too.

12. Press Information Bureau (11 September 2014). "Round up at 1800 Hrs- Over 1,10,000 People Rescued So Far by Armed Forces Another Batch of Marine Commandos Arrives in Srinagar". PIB, Government of India. Ministry of Defence. Retrieved 12 September 2014.

Acknowledgements

14. Firstpost. "Army calls off its rescue mission in J&K, relief work to go on". Retrieved 29 September 2014. 14.

13. ANI (6 September 2014). "J-K floods: Indian Army in aid to civil administration under 'Operation MEGH RAHAT'". Udhampur: ANI News. ANI. Archived from the original on 13 September 2014. Retrieved 13 September 2014.

NIL

15. METZLER EC, KODALI BS, URMAN RD, FLANAGAN HL, REGO MS, VACANT JC. Strategies to maintain operating room functionality following the complete loss of the recovery room due to an internal disaster. Am J Disaster Med. 2015 Winter; 10 (1): 5-12.

Potential Conflict of Interest. No conflict of interest exists for any author. Privacy and confidentiality. No personal information has been divulged

16. BOWERS PJ, MAGUIRE ML, SILVA PA, KITCHEN R. Everybody out! Will your facility’s evacuation procedures withstand a disaster? Nurs Manage. 2004 Apr; 35 (4): 504.

REFERENCES 11. SHAO X. The role of health sectors in disaster preparedness. Floods in southeastern China, 1991. Prehosp Disaster Med. 1993 Apr-Jun; 8 (2): 173.

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17. KURUPPU KK. Management of blood system in disasters. Biologicals. 2010 Jan; 38 (1): 87-90.

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Risk of heat-related injury to disaster relief workers in a slow-onset flood disaster. J Occup Environ Med. 1996 Jul; 38 (7): 689-92.

18. Flood fails to 'wash out' ED’s ability to communicate ED Manag. 2008 Sep; 20 (9): 101-2. 19. TOMIO J, SATO H, MIZUMURA. Interruption of medication among outpatients with chronic conditions after a flood. Prehosp Disaster Med. 2010 Jan-Feb; 25 (1): 42-50.

31. FILMER LB, RANSE J. Who is my leader? A case study from a hospital disaster scenario in a less developed country. Australas Emerg Nurs J. 2013 Nov; 16 (4): 170-4. doi: 10.1016/j.aenj.2013.08.004.

20. THONGTAEPARAK W, PRATCHYAPRUIT WO, KOTANIVONG S, SIRITHANAKIT N, THUNYAHARN S, RANGSIN R, CHAIKAEW P, WONGYONGSIN P, PINYOBOON P, SUTTHIWAN P, THEETHANSIRI W, JANTHAYANONT D, MUNGTHIN M. Prevalence of and Risk Factors for Skin Diseases Among Army Personnel and Flood Victims During the 2011 Floods in Thailand. Disaster Med Public Health Prep. 2016 Aug; 10 (4): 570-5.

32. 2014 India Pakistan Floods. Accessed at WikiPedia at ps://en.wikipedia.org/wiki/2014_India – Pakistan_floods 33. KONDAVETI R, GANZ A. Decision support system for resource allocation in disaster management. Conf Proc IEEE Eng Med Biol Soc. 2009; 2009: 3425-8.

21. WOOD M, KOVACS D, BOSTROM A, BRIDGES T, LINKOV I. Flood risk management: U.S. Army Corps of Engineers and layperson perceptions. Risk Anal. 2012 Aug; 32 (8): 134968.

34. CLINTON JJ, HAGEBAK BR, SIRMONS JG, BRENNAN JA. Lessons from the Georgia floods. Public Health Rep. 1995 Nov-Dec; 110 (6): 684-8. 35. MURPHY MW, IQBAL S, SANCHEZ CA, QUINLISK MP. Postdisaster health communication and information sources: the Iowa flood scenario. Disaster Med Public Health Prep. 2010 Jun; 4 (2): 129-34.

22. D’AMORE AR, HARDIN CK. Air Force expeditionary medical support unit at the Houston floods: use of a military model in civilian disaster response. Mil Med. 2005 Feb; 170 (2): 103-8.

36. SAPIR DG. Natural and man-made disasters: the vulnerability of women-headed households and children without families. World Health Stat Q. 1993; 46 (4): 227-33.

23. RAY K, BHAN SC, BANDOPADHYAY BK. The catastrophe over Jammu and Kashmir in September 2014: a meteorological observational analysis. Current Science 2015; 109 (3): 580-591.

37. MARTIN ML. Child participation in disaster risk reduction: the case of flood-affected children in Bangladesh. Third World Q. 2010; 31 (8): 1357-75.

24. Floods in J&K. Department of Ecology Environment and Remote Sensing J&K. J&K ENVIS center. Accessed at http://www.jkenvis.nic.in/ecotalk_flood_jk.html at 20 Feb 2018.

38. IVERS LC, RYAN ET. Infectious diseases of severe weatherrelated and flood-related natural disasters. Curr Opin Infect Dis. 2006 Oct; 19 (5): 408-14.

25. ALDERMAN K, TURNER LR, TONG S. Floods and human health: a systematic review. Environ Int. 2012 Oct 15; 47: 37-47.

39. APISARNTHANARAK A, MUNDY LM, KHAWCHAROENPORN T, GLEN MAYHALL C. Hospital infection prevention and control issues relevant to extensive floods. Infect Control Hosp Epidemiol. 2013 Feb; 34 (2): 200-6.

26. DOOCY S, DANIELS A, MURRAY S, KIRSCH TD. The human impact of floods: a historical review of events 1980-2009 and systematic literature review.

40. MILOJEVIC A, ARMSTRONG B, HASHIZUME M, MCALLISTER K, FARUQUE A, YUNUS M, KIM, STREATFIELD P, MOJI K, WILKINSON P. Health effects of flooding in rural Bangladesh. Epidemiology. 2012 Jan; 23 (1): 107-15.

27. DU W, FITZGERALD GJ, CLARK M, HOU XY. Health impacts of floods. Prehosp Disaster Med. 2010 May-Jun; 25 (3): 265-72. 28. WISITWONG A, McMILLAN M. Management of flood victims: Chainat Province, central Thailand. Nurs Health Sci. 2010 Mar; 12 (1): 4-8.

41. EMERSON JB, KEADY PB, BREWER TE, CLEMENTS N, MORGAN EE, AWERBUCH J, MILLER SL, FIERER N. Impacts of flood damage on airborne bacteria and fungi in homes after the 2013 Colorado Front Range flood. Environ Sci Technol. 2015 Mar 3; 49 (5): 2675-84.

29. LARSEN B, GRAHAM T, AISBETT B. A survey to identify physically demanding tasks performed during storm damage operations by Australian State Emergency Services personnel. Appl Ergon. 2013 Jan; 44 (1): 128-33.

42. KOLEN B, HELSLOOT I. Time needed to evacuate the Netherlands in the event of large-scale flooding: strategies and consequences. Disasters. 2012 Oct; 36 (4): 700-22.

30. DELLINGER AM, KACHUR SP, STERNBERG E, RUSSELL J.

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International Review of the Armed Forces Medical Services

Revue Internationale des Services de Santé des Forces Armées

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A RT ICLES

Particularités des lésions thoraciques dans un hôpital de maintien de la paix : cas de l’hôpital niveau 2 du Togo déployé à KIDAL (MALI). Par D. LAMBONI∑, H.D. SAMA∑, K. ASSOGBA∏, A. AMAVI∑, K. AKLOA∑, S. ASSENOUWE∑, G. AKALA, Y. AKPOTO∑, M. AKPANAHE∑, B. KOUTORA∑, F. GNANDI-PIOUπ, K.E. MOSSI∑ et A. ABALO∑. Togo

Damessane LAMBONI Le Médecin Commandant LAMBONI Damessane est le 28 mars 1983 à Lomé (TOGO). Médecin Commandant des Forces Armées Togolaises, il est chirurgien général et thoracique à la clinique médico-chirurgicale (Pavillon Militaire) du CHU Sylvanus Olympio de Lomé (Togo). DIPLOMES UNIVERSITAIRES • Octobre 2016 : Module Universitaire de Chirurgie de Guerre, Université de Lomé. • Novembre 2015 : Diplôme National de spécialité en Chirurgie Thoracique obtenu à la Faculté de Médecine de Rabat-Maroc. • 2007-2010 : Internat de Chirurgie Générale à la faculté des Sciences de la Santé de Lomé (Togo). • Janvier 2009 : Doctorat d’état en Médecine à la faculté des Sciences de la Santé de Lomé (Togo). DIPLOMES MILITAIRES • 2004 : Brevet de Parachutisme militaire. MISSIONS EX TERIEURES • 3 mars 2016 au 9 septembre 2016 : Chirurgien à l’Hôpital niveau 2 du Togo à Kidal dans le cadre de la Mission Multidimensionnelle des nations unies pour la stabilisation du Mali (MINUSMA). • A partir du 28 mars 2018 : Chirurgien à l’Hôpital niveau 2 du Togo à Kidal dans le cadre de la Mission Multidimensionnelle des nations unies pour la stabilisation du Mali (MINUSMA). DECORATIONS • Chevalier de l’Ordre National de Mérite (Togo). • Médaille du Soldat de la paix au Mali.

SUMMARY Particularities of thoracic lesions in a peacekeeping hospital: case of TOGO’S level 2 hospital in KIDAL, MALI. Background: Chest inj uries are responsible for significant morbidity and mortality in armed conflict. The aim of our work is to report the thoracic lesions observed in a United Nations front Hospital. Material and method: We conducted a retrospective study in the Togo level 2 hospital deployed in Kidal on patient records files. All patients admitted for thoracic inj ury over a period from January 1, 2014 to May 3 1, 2018 were included. Results: Fifty-two patients were hospitalized during the study period. The average age was 28.5 years with extremes of 16 and 52 years. Most of them were peacekeepers (88.5%). Vulnerable agents were 69.2 % weapons of war and 30.8% were road accidents. The thoracic lesions were rib fractures (13.4 %), parietal contusions 34.6%, thoracic wounds 53.8%, pleural effusions 15.4 %, pulmonary bruises 3.8% and lung blasts 3.8%. Extra thoracic inj uries accounted for 57.7% of cases. Therapeutic management consisted of pleural drainage 9.6%; resuscitation measures 15.4 % and functional medical treatment. The evolution was favorable in 57.7% of cases, 26.9% were referred to a higher level and 1.9% of deaths were noted.

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Conclusion: The thoracic lesions observed in a hospital level II of the UN are caused by various wounding agents combining road trauma and war lesions. They are generally benign and are due to the importance of the means of protection implemented.

KEYWORDS: Thoracic lesions, Level 2 hospital, Peace, Sahelo-Saharan band. MOTS -CLÉS : Lésions thoraciques, Hôpital de Niveau 2, Paix, Bande sahélo-saharienne . International Review of the Armed Forces Medical Services

Revue Internationale des Services de Santé des Forces Armées

INTRODUCTION

(CASEVAC)) par voie aérienne vers un hôpital de niveau supérieur.

Les lésions thoraciques au cours des derniers conflits armés sont responsables d’une morbi-mortalité non négligeable1, 2. Ceci s’explique par la multiplicité des agents vulnérants qui sont utilisés afin d’accroître l’effet délétère des armes de guerre. Les missions de maintien de la paix n’en sont pas exclues. La Mission multidimensionnelle des Nations Unies pour la Stabilisation du Mali (MINUSMA) considérée comme la plus dangereuse des missions onusiennes depuis sa création3 se trouve confrontée à ces armes de conflit. Pour faire face à ce défi, une chaîne de prise en charge sanitaire est organisée par niveau. L’hôpital de niveau (HN2) du Togo déployé à Kidal a, dans cette optique, pour but la prise en charge chirurgicale notamment la stabilisation des blessés et leur transfert si besoin à un niveau supérieur.

L’HN2-Togo assure également un soutien médical aux populations civiles dans le cadre des Actions CiviloMilitaires (ACM). Conformément aux normes Onusiennes, l’HN2-Togo a la capacité de réaliser par jour 3 à 4 interventions chirurgicales, 40 consultations externes et 5 à 10 consultations dentaires; La capacité d’hospitalisation est de 10 à 20 blessés pendant sept jours au maximum.

Moyens humains et matériels de l’HN2-Togo. L’HN2-Togo dispose de dix praticiens hospitaliers militaires avec deux chirurgiens généralistes, un médecin anesthésiste réanimateur, un médecin interniste, un médecin généraliste, un chirurgien-dentiste, deux médecins urgentistes en charge des MEDEVAC/CASEVAC par voie aérienne et un médecin responsable de l’hygiène hospitalière et environnementale. L’effectif est complété par 26 paramédicaux. Le plateau technique comprend : - deux blocs opératoires. - une salle d’accueil et de tri. - une salle d’urgence et de réanimation à deux lits. - une salle de soins post-interventionnelle et de soins intensifs à deux lits. - un secteur d’hospitalisation conventionnelle de 20 lits. - une salle de radiodiagnostic avec un appareil de radiographie fixe, un appareil de radiographie mobile et deux échographes. - un laboratoire d’analyses médicales avec une banque de produits sanguins labiles. - un cabinet dentaire. - une pharmacie.

Le but de notre étude est de recenser les différentes lésions thoraciques observées, de préciser les agents vulnérants et de noter leur morbi-mortalité des lésions thoraciques dans un hôpital de l’avant des Nations Unies.

MATERIELS ET METHODES 1. Cadre d’étude L’hôpital niveau 2 du Togo a été déployé dans le cadre de la MISMA (Mission pour la Stabilisation du Mali) en 2013. Il a été initialement déployé à SEVARE au centre du Mali puis après passage de la MISMA (Mission Internationale de Soutien au Mali) à la MINUSMA (Mission Multidimensionnelle des Nations Unies pour la stabilisation de Mali), il a été redéployé à Kidal au Nord du MALI.

L’hôpital niveau 2 dispose d’une morgue qui reçoit les dépouilles de tout personnel des Nations Unies (NU) au niveau du secteur Nord de la MINUSMA.

La ville de KIDAL est située au nord du Mali à 1 500 km de la capitale Bamako. Elle est dans le secteur Nord de la MINUSMA. Sur le plan géostratégique, le centre et le nord du Mali est revendiqué par les groupes indépendantistes Touaregs, ce qui a abouti à une rébellion contre le pouvoir central Malien en 2013. Dans l’offensive contre le pouvoir central malien, des alliances ont été créées avec certains groupes terroristes qui existaient préalablement dans la zone sahelo-saharienne. Après l’intervention des forces Françaises à travers l’opération « SERVAL », les groupes djihadistes ont été partiellement anéantis et la MINUSMA a été déployée afin de maintenir la paix entre les groupes indépendantistes et le pouvoir central de Bamako. Cependant sur le territoire, des attaques terroristes par mines, Engins Explosifs Improvisés (EEI), attaques indirectes et attaques directes sont récurrentes contre les forces internationales. Cette situation est plus observée dans le secteur Nord de la MINUSMA.

2. Méthodologie Nous avons procédé à une étude rétrospective descriptive de tous les cas de traumatisme du thorax sur une période s’étendant du 1er janvier 2014 au 31 mai 2018 soit une durée de 53 mois. Les dossiers médicaux d’hospitalisation étaient utilisés pour la collecte de données ainsi que les rapports médicaux postmortem des patients décédés avant l’admission à l’HN2. Nous avons recueilli des informations concernant l’identité des patients, leur statut, les lésions thoraciques présentées, les lésions associées, le traitement réalisé et leur évolution. ∑ Clinique médico-chirurgicale du CHU Sylvanus Olympio de Lomé (TOGO).

La mission principale de l’HN2-Togo est de soutenir les forces de la MINUSMA en offrant des soins urgents de sauvetage et de stabilisation (diagnostic et prise en charge des urgences médicales et chirurgicales, réanimation et stabilisation des blessés ou autres patients graves), des soins dentaires et en assurant les évacuations médicales (MEDical EVACuation (MEDEVAC) et CASualty EVACuation

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∏ CHU Campus de Lomé (TOGO). π CHU Campus de Lomé (TOGO). Correspondance : Médecin Commandant Damessane LAMBONI Chirurgien Générale et Thoracique des Forces Armées Togolaises, Clinique médico-chirurgicale du CHU Sylvanus Olympio de Lomé (TOGO) E-mail : damsane@yahoo.fr

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Les données ont été enregistrées sur le logiciel EXCEL s oLes résultats s t ont été r gi ré s spar r le même lo ic llogiciel. E 2010. obtenus 01 . r s l ts o l ê e l ici .

Les lésions thoraciques observées sont enregistrées s r es s nre is dansl leitableau raci N°II es ns l bl a I

Les variables ont été exprimées en pourcentage et en es i l s o été ex ri s o moyenne. e

Les lésions pleurales ont concerné 8 patients, soit l r l causées o ie s, soi 15,4 l%.i Elles étaient parcern les EEI (4 patients), les . ll ie t s es r les ( s) l éclats d’obus de mortier (2), une explosion dei véhicule l ts us ete balle d’arme ier ), à feu e (1). pl Tous s i kamikaze (1) les patients i (1) b ll ’ar fe (1). T s l ati ayant une lésion pleurale présentaient des lésions t e lési associées.l prése tai nt s l i extrathoraciques i s s i es. Nos patients présentaient des lésions extrathoraciques s 57,7 ati % t des cas (31 i patients). l s Il s’agissait r t de itraudans ns 7, ( 1 ati . Il ’ gi e matisme crânio-encéphalique (TCE) chez 6it patients is cr ni ncé li ( ) ati %); (11,5 %); lésions abdominales chez 7 patients (13,5 1 ,5 ); io b i l s ez i ( ) musculo-squelettiques, 23 patients (44,2 %) et de blasts l -sq l tti es 2 p ti ts ( , las auriculaires chez 4 patients (7,7 %). ri lai c p ti nts ( , . Les patients décédés avant l’admission (7 cas) préseni s des plaies s transfixiantes nt ’a i io thoraciques ( cas) taient tous et 4 ie t l i s tr nsf ia s th iq présentaient en plus des lésions extrathoraciques. Les i l étaient s s l composés i s extr desoraci s. agents vulnérants éclatsu d’obus ts l (6 éracas) ts et un i projectilesés es àclfeu (1’ocas) . deemortier d’arme i r (6 c s et n roj il à 1 cas . La prise en charge thérapeutique de ces lésions a ri en e un drainage r e e tichez 5 epatients l (9,6 i s %) consisté pleural s sté drai a le r l ie s ,6

RESULTATS Sur la période d’étude, 52 patients ont été admis à l’hôr la niveau éri e2 du ’ TOGO pour ti des t lésions été thoraciques i l’ ôpital i l i ea p l si s oraci post-traumatiques, soit une incidence de 1 cas/mois.esIl st- r de 7i décès u s, avant it u l’admission, inci e i .45l s’agissait soit 13,5 /% et ’ iss t e 7 c s l is i , i 13, et patients admis vivants à l HN2. Parmi ces 7 patients 3 ati is au cours ld’attaque . i ts étaient décédés indirecte duiesuperi és c rs ta i irect u s camp de Kidal, 2 dans les environs de Kidal (positionse < id l de l’HN2) s l sete 2 lors ir nsde l’attaque e i l indirecte siti s avancées 5 km a l’ e l’ e i irec du camp d’Aguelok (130 km de Kidal). d c ’ g l ( 0 i l). Tous étaient de sexe masculin avec une moyenne d’âge o 28,5 ans i s li ave y de avecsex des extrêmes de 16 à 52 ans. Il s’agisdsait2de , 46 soldats s c desla paix (88,5 s e%), 16 1àcombattant 2 ns. I s d’unsgroupe e armé l (1,9 s %), la de ai 4 ( civils , ),non 1 personnels att nt des ro r , ), ci il l es Nations Unies (7,7 %) et 1 personnel civil desnNations i i ( et 1 ers n l ci il s ati Unies (1,92 %). Les agents vulnérants étaient dominéss ). par a éclats d’obus, l nt o i és pari sles ,blessures laétai traumatologie ar l l l s ’o , l l gi routière représentait le 1/3 des patients (tableau I). uti re it l 1/ ie s l I). Tableau I : Causes des lésions thoraciques. i t or ci . l I : a ses CAUSES S

Eclats d’obus (IDF) lat d’ us (I AVP P EEI / Mine I ine Arme à feu r à e Explosion (véhicule kamikaze) l si ( ic l i ) Accident de travail c ide t tra il TOTAL

NOMBRE MBRE (N) DE PATIENTS DE A IEN ( 18

16 9 9 5 5 3 3 1 1 52

AVP : accident de la voie publique. IDF :: indirect ccide tfire. la voie liq . N : nombre cas. IDF : i directde fire. %: : poubrce e ntage. as. : ource age.

Figure 1 : Plaie thoracique par arme à f eu, Figure 1 : Plaie thoracique par arme à f eu,

POURCENTAGE CENT (%) ( ) 34,6 ,6 30,8 ,8 17,3 ,3 9,2 9, 5,8 5, 1,9 1, 100 100

Tableau II : Lésions thoraciques observées. a l u I: é iques es.

LÉSIONS SI

Contusion pariétale t io pari tal Fracture de côtes ct r c Plaies thoraciques lai t or iq s Contusion pulmonaire t io pul ire Blast pulmonaire l st l ai Epanchement pleural c e pl l VOL. 92/1. /1

N : nombre de cas. %: : poubrce e ntage. as. : ource age.

Pauci costales (<3) Pauci cos les (<3) Pluricostales (≥3) Pl ic s les ( 3) Pariétales Pari tal Pénétrantes (transfixiantes) Pénétr ( rans ixi s)

18 1 4

34,6 34, 7,7 , 5,8 ,8 34,6 34, 19,2 19, 3,8 ,8 3,8 ,8 3,8 ,8 1,9 ,9 9,6 ,6

3 3 18 1 10 1 2 2 2 2 2 2 1 1 5 5

Hémothorax othora Pneumothorax Pne othor Hémopneumothorax o t rax

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Figure 2 : Plaie thoracique par arme à f eu, orif ice de sortie, axillo-thoracique gauche.

et des mesures de réanimation en soins intensifs chez 8 patients (15,4 %). Cette réanimation consistait en une oxygénothérapie chez 5 patients, une intubation orotrachéale avec ventilation mécanique chez 5 patients, une transfusion sanguine chez 4 patients et l’utilisation d’amines vasopressives chez 2 patients. Le traitement médical a comporté des antalgiques, des anti-inflammatoires et au besoin des antibiotiques chez tous les patients.

1 cas/mois. Ces lésions étaient dues à des agents vulnérants divers. Les accidents de la voie publique ont été à l’origine du 1/3 des lésions thoraciques autant que les blessures par obus de mortier. Cette pro portion des accidents de la voie publique est néanmoins moindre que celle retrouvée par Appenzeler dans la mission de la paix des Nations Unies au Kosovo9 où 72 % des lésions traumatiques retrouvées étaient dues aux accidents de la voie publique9 . L’étendue de la zone de déploiement de la MINUSMA mais également les attaques asymétriques qui y sont courantes expliquent cette diversité des causes des lésions. Les lésions par arme blanche ne sont pas observées dans notre série contrairement aux données rapportées dans d’autres missions des Nations Unies, comme au Rwanda10 . Les lésions thoraciques au cours de la mission de maintien de la paix au Kosovo étaient estimées à 5,7 % de toutes lésions observées et arrivaient en avant-dernière position après les lésions de la tête et du cou (29,5 %), des membres (33,4 %) et avant les lésions abdominales (4,5 %). Les lésions multiples étaient estimées à 27 %9 . Figure 3 : Radiographie du thorax montrant une opacité basale gauche et une opacité pariétale axillaire gauche + emphysème sous-cutané gauche.

L’évolution sous traitement a été favorable chez 29 patients (57,7 %). Il y a eu 1 cas de décès à l’HN2 (1,9 %) et 14 patients (26,9 %), tous avec des lésions extrathoraciques associées, ont été évacués à un niveau supérieur pour un complément de prise en charge.

COMMENTAIRES-DISCUSSION Les traumatismes thoraciques avec les plaies du thorax dans les conflits armés récents (IRAK et AFGHANISTAN) ont concerné 10 % des blessés et la mortalité associée s’élevait à environ 10 %1, 2 . Les hémorragies du tronc représentaient la principale cause de mort évitable dans 47 à 67 % des cas4 ,5. La mission de maintien de la paix des nations unies au Mali (MINUSMA) s’inscrit au chapitre 6 du mandat des nations unies 6 . De ce fait, elle a pour but de consolider la paix. Les situations de combat des missions de la paix ne sont pas similaires aux conflits directs observés ces dernières décennies dans d’autres situations de conflits. La chaîne de soutien médical est également complexe vu l’impact de l’environnement sécuritaire dégradé et de la zone de responsabilité de la MINUSMA 7, cet environnement sécuritaire est en partie responsable de l’ « élongation » du délai de prise en charge des patients expliquant la proportion des décès avant admission malgré que 3 malades sur 7 ont été blessés dans le « supercamp » de Kidal.

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Figure 4 : Mise en p lace d ’un drain p leural axillaire gauche.

Les soins médico-chirurgicaux de l’HN2 TOGO au profit du personnel de la MINUSMA et au profit de la population civile ont été importants comme l’a montré Sama8 . Durant notre période d’étude, l’HN2 a réalisé 1 311 actes chirurgicaux, les lésions thoraciques en représentaient environ 4 % et avaient une incidence de

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La majorité des lésions thoraciques observées dans notre série étaient bénignes et consistaient en des contusions de la paroi thoracique, des fractures de côtes et des plaies pariétales. Le contexte de « paix précaire » explique cette majorité des lésions thoraciques bénignes contrairement aux lésions thoraciques qui sont observées en situation de guerre comme en Afghanistan. Dans un hôpital de référence de niveau 3, sur une durée de 52 mois, 89 plaies thoraciques de guerre ont été observées soit 1,7 cas de plaies thoraciques ayant entraîné 60 % d’hémothorax, 39 % de pneumothorax, 37 % de plaies diaphragmatiques, 35 % de plaies du parenchyme pulmonaire et 20 % de plaie du cœur ou des gros vaisseaux 11.

La mortalité de ces lésions observées à l’Hôpital niveau 2 a été de 1,9 %. Ceci peut s’expliquer par l’amélioration de la chaîne d’évacuation sanitaire et les normes de standard Onusienne imposées aux hôpitaux de niveau 2 déployés. Une idée plus globale de la mortalité des lésions thoraciques pourrait être obtenue si un suivi jusqu’au niveau supérieur, 2 + ou trois avait été prise en compte. Compte tenu du caractère rétrospectif de notre étude, les scores de gravité notamment l’Injury Severy Score (ISS) n’ont pas été notés, de plus l’absence de registre national en opérations extérieures n’a pas permis de collecter des données exactes sur l’itinérance des patients depuis le lieu d’impact, leur transfert à l’HN2 ainsi que le devenir des patients évacués vers un niveau supérieur.

Le Nord-Mali ne s’exclut pas du contexte épidémiologique et des menaces terroristes actuelles dans le monde. Les attaques Kamikazes et les attaques asymétriques par EEI et tirs indirects entraînent des lésions de type primaire, secondaire, tertiaire voire quaternaire qui sont dotées d’une létalité plus importante comparativement aux autres traumatismes 12, 13 . Nous retrouvons dans notre série la particularité des lésions thoraciques par blast et par éclats d’obus de mortier. Ceci explique également les lésions extrathoraciques observées chez 57,7 % des patients.

Figure 6 : Parage chirurgical de l ’orif ice de sortie.

La prise en charge médicale de nos patients était en majorité simple par des antalgiques et les anti-inflammatoires avec 57,7 % d’évolution favorable. La prise en charge chirurgicale a consisté essentiellement en un drainage thoracique (9,6 %). Aucune thoracotomie n’a été réalisée contrairement à d’autres études 11. L’évolution favorable de la majorité des patients s’explique par la prépondérance des affections bénignes. Certains patients ont eu besoin de soins de réanimation dans les états de choc hémodynamique et les états de détresse respiratoire. Le pronostic de nos patients et leur transfert à un niveau supérieur de la chaîne médicale étaient liés à l’existence de lésions extrathoraciques associées. Ceci a été également retrouvé par POON14 .

CONCLUSION Les lésions thoraciques observées dans un hôpital de l’avant de l’ONU étaient causées par des agents vulnérants divers alliant la traumatologie routière et les blessures de guerre. Fort heureusement, ces lésions étaient majoritairement bénignes et leur prise en charge était en générale favorable. Ceci peut s’expliquer par le type d’opération militaire réalisée mais aussi par les moyens de protection utilisée dans les missions de l’ONU.

Figure 5 : Radiographie du thorax de contrôle montrant le drain p leural en p lace et une évacuation de l ’hémothorax gauche.

RÉSUMÉ Introduction Les lésions thoraciques sont responsables d’une morbimortalité non négligeable dans les conflits armés.

L’objectif de notre travail a été de rapporter les lésions thoraciques observées dans un Hôpital de l’avant des Nations Unies. Matériel et méthode Nous avons procédé à une étude rétrospective dans l’hôpital de niveau 2 du Togo déployé à Kidal sur les dossiers de patients hospitalisés. Etaient inclut tous les patients admis pour traumatisme du thorax sur une période s’étendant 1er janvier 2014 au 31 mai 2018.

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Résultats Cinquante-deux patients ont été hospitalisés pendant la période d’étude. L âge moyen était de 28,5 ans avec des extrêmes de 16 et 52 ans. Il s’agissait en majorité de soldats de la paix (88,5 %). Les agents vulnérants étaient des armes de guerre 69,2 % et des accidents de la voie publique 30,8 %. Les lésions thoraciques étaient des fractures de côtes (13,4 %), des contusions pariétales 34,6 %, des plaies thoraciques 53,8 %, des épanchements pleuraux 15,4 %, des contusions pulmonaires 3,8 % et des blasts pulmonaires 3,8 %. Les lésions extrathoraciques représentaient 57,7 % des cas. La prise en charge thérapeutique a consisté en un drainage pleural 9,6 %; en des mesures de réanimation 15,4 % et un traitement médical fonctionnel. L’évolution a été favorable dans 57,7 % des cas, 26,9 % ont été référés à un niveau supérieur et on a noté 1,9 % de décès.

for the future of combat casualty care. J Trauma Acute Care Surg . 2012; 73 (6 Suppl 5) : S431-7. 15. HOLCOMB J, CARUSO J, MCMULLIN N, WADE CE, PEARSE L et al. Causes of death in US Special Operations Forces in the global war on terrorism : 2001-2004. US Army Med Dep J. 2007; 24-37. 16. Mission multidimensionnelle intégrée des Nations unies pour la stabilisation au Mali (MINUSMA) (2017). Mandat. Accessible le 20 août 2017 sur https:// minusma.unmissions.org/ mandat-0. 17. SAMA H.D, ADAM S, BISSA H, LAMBONI D, AKPANAHÈ M, TOMTA K, DJIBRI M, GUNEPIN M. Complexité de la chaîne de soutien médical opérationnel au cours d’une mission des Nations unies en Afrique subsaharienne. À propos d’un cas. Méd. Intensive Réa (2017) 26 : 528-534.DOI 10.1007/s13546-017-1313-9 18. SAMA H.D, ADAM S, BISSA H, AKPOTO MY et coll. Bilan d’activité de l’Hôpital militaire togolais de Niveau 2 déployé au Mali et perspectives pour le soutien médical des forces de l’Union Africaine. Revue internationale des Services de Santé des Forces Armées 2017; 90 (2) : 29-36.

Conclusion Les lésions thoraciques observées dans un hôpital de l’avant de l’ONU sont causées par des agents vulnérants divers alliant la traumatologie routière et les lésions de guerre. Elles sont généralement bénignes et sont dues à l’importance des moyens de protection mis en œuvre.

19. APPENZELLER GN. Injury patterns in peacekeeping missions : the Kosovo experience. Military Medical 2004; 169 (3) : 187-191.

CONFLITS D’INTÉRÊTS

10. FARROW GB, ROSENFELD JV, CROZIER JA, HEATLEY P, WARFE P. Military Surgery in Rwanda. Aust N Z Journal Surgery 1997; 67 (10) : 696-702.

Nous ne déclarons aucun conflit d’intérêts RÉFÉRENCES

11. De LESQUEN H, BÉRANGER F, BERBIS J, FORD RM et coll. Traumatismes thoraciques de guerre en Afghanistan : analyse du registre du service de Santé des armées Français. e-mémoires de l’Académie Nationale de Chirurgie 2015; 14 (4) : 70-76.

11. KENEALLY R, SZPISJAK D. Thoracic trauma in Iraq and Afghanistan. J Trauma Acute Care Surg . 2013; 74 : 1292-7. 12. IVEY KM, WHITE CE, WALLUM TE, ADEN JK, CANNON JW, CHUNG KK et Coll. Thoracic injuries in US combat casualities : a 10-year review of operation Enduring Freedom and Iraqi Freedom. J trauma Acute care Surg . 2012; 73 (6 Suppl 5) : S514-9.

12. CLAPSON P, PASQUIER P, PEREZ JP, DEBIEN B. Lésions pulmonaires liées aux explosions. Revue de Pneumologie clinique 2010; 66 : 245-253. 13. KLUGER Y. Bomb explosions in act of terrorism-detonation, wound ballistics, triage and medical concerns. Isr Med Assoc J 2003; 5 : 235-40.

13. Mission multidimensionnelle intégrée des Nations unies pour la stabilisation au Mali (MINUSMA) (2015). Les évacuations médicales de la MINUSMA. Accessible le 10 mai 2017 sur https://minusma.unmissions.org/les-%C3%A9vacuations-m%C3% A9dicales-de-la-minusma

14. POON H, MORRISSON JJ, APODACA AN, KHAN MA, GARNER JP. The UK military experience of thoracic injury in the wars in Iraq and Afghanistan. Inj ury 2013; 44 : 116570 doi : 10.1016/j.injury.2013.01.041 Epub 2013 feb 20.

14. EASTRIDGE BJ, MABRY RL, SEGUIN P, CANTRELL J, TOPS T et al. Death on the battlefield (2001-2011) : implications

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A RT ICLES

From Organ Support to Organism Support: Extra Corporeal Membrane Oxygenation in Military Combat Trauma.* By V. SRIVASTAVA∑, NS. LAMBA∏, M. NAKRAπ and A. SHANKAR∫. India

Vikas SRIVASTAVA Colonel Vikas SRIVASTAVA is an Anaesthesiologist & Intensivist Doctor in Indian Army since 19 years in speciality. He works at the Army Hospital (R&R) in the Department of Anaesthesiology and Critical Care. EDUCATION MBBS - AFMC, Pune 1992. MD (Anaesthesiology) - AFMC, Pune 2002. IDCCM (Sir Ganga Ram Hospital, New Delhi) 2010. IFCCM (Sir Ganga Ram Hospital, New Delhi) 2011. EDIC (European Diploma Intensive Care Medicine) 2012. Certification in Public Health Research from Harvard University, USA (2012). ACLS, ATLS. SPECIAL INTERESTS Sepsis, Difficult Airway, Nutrition, Monitoring, Invasive lines. A CADEMIC PURSUITS 05 International publications. Presented various papers in National Conferences.

RESUME Du maintien en vie d’un organe à celui d’un organisme : l’oxygénation extracorporelle sur oxygénateur à membrane appliq uée aux traumatismes de guerre. Un traumatisme est une atteinte complexe pour un patient et non pas j uste une hémorragie ou une atteinte mécanique. Le principe des soins devrait être de rétablir l’état physiologique le plus rapidement possible pour permettre à l’organisme de survivre à cette grave atteinte. L’oxygénation extracorporelle sur membrane (ECMO) rétablit rapidement cet état physiologique à un état proche de la normale et assure la vascularisation des organes. Jusqu’à une période récente, l’ECMO de veine à veine a été utilisée dans les situations de Syndrome de détresse respiratoire aiguë (SDRA) et la littérature est abondante à ce suj et. Chez les traumatisés à risque d’hémorragie, l’ECMO veino-artérielle (VA ECMO) peut être maintenant utilisée grâce aux tubulures et aux filtres recouverts d’héparine. Les ensembles d’organe ayant souffert d’ischémie ne sont pas lésés et l’évolution devient favorable. Si le cœur a été un moment sidéré ou si le système cardiovasculaire a souffert d’acidose, l’ECMO rétablit la circulation et la triade létale se trouve stoppée de façon miraculeuse. Le remplissage veineux de la réanimation peut être responsable de suintements veineux difficiles à contrôler. Dans la VA ECMO, le système veineux est vidé ce qui réduit ce risque de suintement. L’ECMO permet aussi un accès artériel au patient chaque fois que c’est nécessaire. Le circuit d’ECMO peut être utilisé pour l’hémodialyse, l’hémofiltration et pour tout traitement par adsorption.

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L’ECMO peut être mise en route dans une structure périphérique et le patient peut être évacué grâce à un dispositif mobile vers un hôpital équipé pour une prise en charge plus complète. Cette technique s’avère très prometteuse.médicaux militaires au cours de la dernière décennie d’opérations e Irak et en Afghanistan.

KEYWORDS: War traumatology, Extracorporeal membrane oxygenation. MOTS -CLÉS : Traumatologie de guerre, Oxygénation ex tracorporelle.

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INTRODUCTION

trauma is not improving over number of years - maybe we have got it wrong as far as our approach is concerned. Out of the trimodal distribution of trauma deaths approximate distribution of deaths is 60% die in the first peak, 30% in the second peak and 10% in the third peak. there are far too many patients who still die in the second and third peak. We can significantly reduce the second peak by looking beyond the ‘Organ Support’ method to a more holistic ‘ORGANISM SUPPORT’ model.

High velocity missile, shrapnel of bullet wound has a devastating effect on haemodynamics inasmuch tissue injury is massive. Reperfusion injury which follows wreaks mayhem with interior melieu. It is much more lethal than a civilian vehicle crash as generally its location is far from any meaningful comprehensive medical care. Trauma is a multi-system insult and any injunction that it is just haemorrhagic shock or mechanical injury could not be farther from the truth6. The foremost course and guidelines by American College of Surgeons1 has compartmentalized trauma into systems and anatomical body zones, but it is the amalgamation of whole body into a single unit which responds to polytrauma in ways which can even baffle experts. The biomechanics of trauma has been area of research since long and deals with most of the trauma associated with Military Medicine like blast injuries, high-velocity projectile injury and road traffic accidents4, 5.

WHAT CAN BE MODIFIED IN POLYTRAUMA From ‘Organ Support’ to ‘Organism Support’ Perhaps our effort should now be based on comprehensive Organism support and normalize the physiology as fast as possible7. Extracting the patient out from the downward spiral of lethal triad of trauma is the key for his survival and early recovery8. The cornerstones of resuscitation were IV fluids, blood products, control of haemorrhage and organ support like ventilation for lungs, inotropes for heart, dialysis for kidneys, reduction of ICP and hope that all the combination of all this proves positive for the patient. However, on many occasions, this therapy does not improve the outcome as is evident from the high mortality rate of trauma. Perhaps there is a need to have a paradigm shift of the mainstay therapy. We need to have a system in place where we can actively terminate the lethal triad and enforce stable haemodynamics in a patient who is unstable9. The system which can radically change outcome is Extra Corporeal Membrane Oxygenation (ECMO).

Conventional knowledge and interventions have been in vogue since long and techniques keep on getting refined with newer researches, but nothing has dramatically changed the outcome of these patients.

WHY NOTHING HAS CHANGED MUCH FOR POLYTRAUMA Has our Knowledge not improved? Our knowledge of polytrauma has reached a plateau. Most of the research is based on ‘Organ Support’. ATLS has compartmentalized human body into organ systems and compartments. Data from the annual mortality data from road traffic accidents (RTA) of India show that 84,674 persons died in 2001 out of 407497 accidents (20.77%) which increased to 142485 persons died in 2011 out of 497686 accidents (28.63%)2. This data contrasts figures in first world countries - in US, 35092 deaths were reported in 2015 and their death rate is 11.32%3. There has been slight decrease in their number of deaths ever since the year 2000 when 41945 had lost their lives. Hence, in India the total numbers and death rate has increased whereas this has decreased in US. It is assumed that decrease in US and other advanced countries may be due to better healthcare delivery systems rather than a paradigm shift in our knowledge. It is also proven beyond doubt that even with massive ‘Organ Support’ and state of the art health infrastructure, significant number of deaths are occurring even in advanced countries. Military trauma is somewhat a taboo topic and exact figures are never known.

EXTRACORPOREAL MEMBRANE OXYGENATION What is ECMO ECMO is akin to cardiopulmonary bypass employed during open heart surgery, only that it is for longer duration lasting days to weeks and maybe months. Wide bore vascular cannulae are placed very close to RA and blood is withdrawn by a magnetic centrifugal pump which pressurises it through oxygenator and back into aorta or IVC. The flow is shown as in Figure 1.

Types of ECMO VV ECMO. Blood is withdrawn from IVC and pumped back into SVC. This system is indicated for haemodynamically stable patients requiring increased oxygenation due to respiratory failure. ∑ Colonel, MD IFCCM. ∏ Major General, MD, PDCC. π Colonel, MD, IDCCM.

It seems that there while there has been improvement of medical infrastructure and faster healthcare delivery, accidents have become even more deadlier than before negating theses improvements.

∫ Colonel MD, EDIC. Correspondence: Colonel Vikas SRIVASTAVA Dept. of Anaesthesiology & Critical Care, Army Hospital (R&R), IND-110010 New Delhi, India. Phone: 9455823000 E-mail: vikas.icu@gmail.com

Are we in a wrong alley? Our knowledge may improve only partially with better education and training facilities, but the outcome of

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* Presented at the 42nd ICMM World Congress on Military Medicine, New Delhi, India, 19-24 November 2017.

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Figure 1: Venovenous extracorp oreal membrane oxygenation (ECMO) conf iguration. (Figure courtesy George WY Ng, Henry J Yuen, KC Sin, Anne KH Leung, KW Au Yeung, KY Lai. Clinical use of venovenous extracorp oreal membrane oxygenation. Hong Kong Med J 2017; 23: 168–76).

(a)

(b) Oxygenated blood

Oxygenated blood

Return cannula

Oxygenator

LV Access cannula

Return cannula

Oxygenator

Motor pump

Deoxygenated blood

Access cannula

Motor pump Oxygenated blood

Deoxygenated blood (a) Venovenous and (b) veno-arterial-venous ECMO circuits Abbrevations: LA = left atrium; LV = left ventricule; RA = right atrium

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VA ECMO. This is indicated for patients who are haemodynamically unstable requiring stabilization of blood pressure. Blood is withdrawn from IVC or SVC or both and pumped into the aorta under pressure mimicking systolic blood pressure. There is minimal blood flow through the heart and pulmonary circuit.

6. Pulmonary Trauma. Severe lung or bronchial injury may not improve by ventilation and in-fact may worsen. ECMO oxygenates blood with minimal pulmonary blood flows. Surge ry o n major bronchial tree becomes much less bloody. ECMO is the only solution which can save patient’s life.

What ECMO can do in Trauma patients?

Indications of ECMO in trauma

ECMO can be a dramatic turning point during treatment of trauma patient. The contribution of this highly invasive modality will be of best use for the following clinical situations: 1. Hypotension. VA ECMO will establish stable haemodynamics almost instantaneously. 2. Hypothermia. ECMO machine has temperature control which can reverse hypothermia or can place a patient in therapeutic hypothermia as required. Temperature control becomes easy. 3. Hypoxia. ECMO is instant treatment of hypoxia. This abolition of hypoxia renders better organ function like heart whose inotropy is restored, AKI is prevented and gut dysfunction is reversed. 4. Diffuse venous ooze. Fluid resuscitation is the cornerstone of trauma treatment. However this accumulates in venous reservoir causing increased ooze from raw areas of trauma which frequently does not respond to conventional measures. ECMO offloads this reservoir and abolishes this nagg ing ooze. 5. Cardiac dysfunction. Chest trauma may cause cardiac stunning and the only possible definitive treatment will be rest to the heart which does not occur by administration of inotropes (which is conventional treatment). VA ECMO offloads blood from pulmonary circuit significantly decreasing cardiac stress without compromising coronary blood flow. This gives rest to cardiac muscle and promotes healing.

ECMO should be instituted in patients with the following derangements: 1. Just after trauma in patients with haemodynamic instability 12 . 2. Patients with injury to heart, lung or major vessels causing instability 10, 11, 13 . 3. Massive fat embolism14 . 4. Generalized ooze causing organ dysfunction and risk of failure of surgery. 5. For control of body temperature when everything else has failed.

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Contraindications Of ECMO in Trauma 1. Un-survivable injury. 2. Multi-organ failure. 3. Early application of ECMO is always better than late. Usually ECMO should not be used as the ‘last resort’ as the outcome may not be favourable.

Indicative Patient Profiles best suited for ECMO in Trauma Patient 1 29 year old serving soldier was on patrol duty at the international border where he was injured in a mine blast injury which resulted in traumatic amputation of both his legs and splinters at multiple places in his body. He was resuscitated, air-evac to forward hospital

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where he was operated with laparotomy and debridement. Postoperatively he was on ventilator, hypotensive, acidotic and generalized ooze was not under control. Massive blood transfusion was given to the patient but still he was critically sick. ECMO team was flown in from Quaternary care hospital, established VA ECMO in about 4 hours time and evacuated the patient to the quaternary care hospital. His blood pressure normalized in a few hours, his ooze was terminated and his condition became better. He was maintained on ECMO for a period of 5 days after which he was weaned off both ECMO and the ventilator.

(one intensivist cannot do it alone), one Nursing officer and one perfusionist. To maintain a patient on ECMO at all times - one Intensivist, one nursing officer, one perfusionist and one nursing assistant is required (total of 4 persons each shift). The manpower should not be reduced at any point of time otherwise outcome may be compromised. The hospital running an ECMO program should have all the super-specialists available for cross consultation viz., Nephrologists for dialysis, Haematologist, Neurologist, Neurosurgeon, Cardiothoracic surgeon, Vascular surgeon, Pulmonologist, GI surgeon, Gastroenterologist etc. Without this manpower, ECMO should not be attempted.

COMPLICATIONS

Patient 2 38 year old serving soldier was riding in the body of a truck which went down a ravine causing multiple injuries including head injury, multiple rib fractures and long bone fractures. He required airevac to the Base Hospital directly from the site of the accident. He was wheeled into the OT immediately where it was found that he had massive Fat Embolism complicating his injuries. ECMO team was requisitioned from the Quaternary care hospital. They established VA ECMO and evacuated the patient. He had a stormy course but within 7 days stabilized and weaned off both ECMO and ventilato r.

ECMO is fraught with massive and catastrophic risks. Some of the common complications are: a. Bleeding - older circuits required high level of anticoagulation but now newer sets have coated lines and may not require anticoagulation. The bleeding risks in trauma patients equal that of the control group24 . b. Air Embolic complications 17 . c. Lower limb ischaemia. d. Circuit, machine and oxygenator failure 18 . e. Malpositioning of cannulae. f. Vessel injuries.

Patient 3 Young 22 year soldier was in a patrol when he was fired upon by militants. Two bullets pierced his chest and he collapsed immediately. Medevac team somehow shifted him to Base Hospital where he was resuscitated with massive transfusion and thoracotomy. However he had severe lung contusions and ventilating him was difficult. ECMO team flew in from Quaternary care hospital and established VA ECMO in a matter of 3 hours. He was flown back to quaternary care hospital for continued superspeciality care. He required two more staged surgeries and ECMO was required for 21 day after which he could be weaned off ECMO and off ventilator after 35 days.

DISCUSSION Photograph of a portable ECMO machine is given in Figure 2 below. Figure 2.

How to establish a successful ECMO program? ECMO is a highly invasive potentially risky proposition which turns out to be life saver for few subset of patients 13, 15, 16 . This requires four pillars for success training, dedication, manpower and adequate infrastructure. Inadequacy of any of the four will result in poor outcome and it will remain a risky therapy. Training - ECMO workshops and fellowships are regularly held in many parts of India. Dedication - There is no dearth in Military set-up. Infrastructure - ECMO is expensive with a transport machine costing about Rs 50 lakhs and a static machine costing Rs 30 lakhs. Disposables for each case will cost about Rs 1.5 lakhs. About 200 sq ft room is required as patient cubicle with all ICU equipment along with ECMO without clutter. Manpower - To initiate ECMO at least 2 Intensivists

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The benefit of ECMO in non-trauma patients are well established after the CESAR trial20 and experience during 2009 H1N119, 23 epidemic. However its use in trauma patients remained an undiscovered enigma due to resource limitations21, 22. The largest series of patients transported on ECMO is from University of Michigan ECMO program which started in 1990. They have reported a successful transport of 220 patients out of 237 (92.8%) out of which they report survival to discharge of 135 patients (62%), which itself is extremely commendable as technological challenges were significant even in first

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and scoot’ technique holds promise with new technology of portable ECMO.

world countries 28 years back25. In India, portable ECMO has been used successfully for transport of critically sick patients by hi-end corporate hospitals but not for casualty air-evac in Government set-up. A search for ECMO centres registered with ELSO (Extracorporeal Life Support Organization) in India shows 16 hospitals26. All are in private sector except AIIMS, New Delhi and none of these are involved in trauma being in safer civilian environment. Trauma in a Military setting has challenges of its own. Establishment of transport ECMO system in Indian Army with one ECMO centre being established in tertiary care centre at is the need of the day. This hospital should have adequate number of Intensivists, perfusionists and nursing officers trained in ECMO. Portable ECMO should be established so that casualties can be given the best care possible. Perhaps PTU (patient Transport Unit) located strategically can incorporate ECMO and various specialists required to achieve this goal.

ECMO helps restore normal physiology. It improves cardiac output, lactate clearance, organ perfusion, pH and urine output. With an appropriate patient selection, VA ECMO in trauma is feasible and advantageous to the patient even with present technology. REFERENCES 11. www.atls.in 12. RUIKAR M. National statistics of road traffic accidents in India. J Orthop Traumatol Rehabil 2013; 6: 1-6. 13. World Health Organization. Global status report on road safety 2015. 14. NAVARRETE-NAVARRO P, RODRIGUEZ A, REYNOLDS N, WEST R, RIVERA R, SCALEA T. Adult respiratory distress syndrome among blunt and penetrating trauma patients: demographics, mortality, and resource utilization over 8 years. J Crit Care. 2001; 16:47 – 53.

CONCLUSION ECMO for critically sick serving soldiers is a niche therapy for those who require super-specialist care but are haemodynamically unstable and cannot be shifted to quaternary care hospital. The benefits of best care is available to them as with ECMO even a sick patient can be air-lifted to the best centre possible. The use of ECMO in trauma patients may provide survival benefits that significantly more than feared risk of complications associated 24.

ABSTRACT Trauma is a complex insult to the patient and not just haemorrhage or mechanical injury. The standard of care should be to support the physiology as quickly as possible to enable body to recuperate from the grave insult. Extra Corporeal Membrane Oxygenation (ECMO) restores the physiology quickly to near normal and ensures organ perfusion. Till recently, veno-venous VV ECMO was used in trauma whenever ARDS used to develop and literature is replete for the same. In trauma patients who are at risk of haemorrhage, veino- arterial VA ECMO can safely be instituted due to recently introduced heparin coated lines and filters. The organ systems which suffer due to ischaemia will be spared the damage and result in better outcome. The heart could be stunned or acidosis could have depressed the CVS, VA ECMO will restore the circulation and magically reverse the lethal triad. The venous loading which occurs with massive fluid resuscitation causes diffuse venous ooze which is difficult to control. In VA ECMO the venous system is emptied which causes reduced ooze. ECMO also ensures adequate vascular access to the patient for any requirement. ECMO circuit can be used for haemodialysis, haemofiltration and any Adsorbent therapy as required.

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ECMO for multisystem trauma can be instituted at the peripheral location and patient can be transported on portable ECMO to a large hospital with ECMO and ancillary facilities for further management. This ‘scoop

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15. ERICKSON SE, MARTIN GS, DAVIS JL, MATTHAY MA, EISNER MD. Recent trends in acute lung injury mortality: 1996–2005. Crit Care Med. 2009; 37: 1574–1579. 16. CALFEE CS, EISNER MD, WARE LB, THOMPSON BT, PARSONS PE, WHEELER AP, KORPAK A, MATTHAY MA. Trauma-associated lung injury differs clinically and biologically from acute lung injury due to other clinical disorders. Crit Care Med. 2007; 35: 2243–2250. 17. PERCHINSKY MJ, LONG WB, HILL JG, PARSONS JA, BENNETT JB. Extracorporeal cardiopulmonary life support with heparin-bonded circuitry in the resuscitation of massively injured trauma patients. Am J Surg. 1995; 169: 488– 491. 18. SENUNAS LE, GOULET JA, GREENFIELD ML, BARTLETT RH. Extracorporeal life support for patients with significant orthopaedic trauma. Clin Orthop Relat Res. 1997: 32–40. 19. MICHAELS AJ, SCHRIENER RJ, KOLLA S, AWAD SS, RICH PB, REICKERT C, YOUNGER J, HIRSCHL RB, BARTLETT RH. Extracorporeal life support in pulmonary failure after trauma. J Trauma. 1999; 46: 638–645. 10. CORDELL-SMITH JA, ROBERTS N, PEEK GJ, FIRMIN RK. Traumatic lung injury treated by extracorporeal membrane oxygenation (ECMO). Injury. 2006; 37: 29–32. 11. HUANG YK, LIU KS, LU MS, WU MY, TSAI FC, LIN PJ. Extracorporeal life support in post-traumatic respiratory distress patients. Resuscitation. 2009; 80: 535–539. 12. ARLT M, PHILIPP A, VOELKEL S, RUPPRECHT L, MUELLER T, HILKER M, GRAF BM, SCHMID C. Extracorporeal membrane oxygenation in severe trauma patients with bleeding shock. Resuscitation. 2010; 81: 804–809. 13. RIED M, BEIN T, PHILIPP A, MULLER T, GRAF B, SCHMID C, ZONIES D, DIEZ C, HOFMANN HS. Extracorporeal lung support in trauma patients with severe chest injury and acute lung failure: a 10-year institutional experience. Crit Care. 2013; 17: R110. 14. BIDERMAN P, EINAV S, FAINBLUT M, STEIN M, SINGER P, Medalion B. Extracorporeal life support in patients with

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multiple injuries and severe respiratory failure: a singlecenter experience? J Trauma Acute Care Surg. 2013; 75: 907–912.

E, THALANANY MM, HIBBERT CL, TRUESDALE A, CLEMENS F, COOPER N, FIRMIN RK, ELBOURNE D. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009; 374: 1351–1363.

15. GUIRAND DM, OKOYE OT, SCHMIDT BS, MANSFIELD NJ, ADEN JK, MARTIN RS, CESTERO RF, HINES MH, PRANIKOFF T, INABA K, CANNON JW. Venovenous extracorporeal life support improves survival in adult trauma patients with acute hypoxemic respiratory failure: a multicenter retrospective cohort study. J Trauma Acute Care Surg. 2014; 76: 1275– 1281.

21. TSAI HC, CHANG CH, TSAI FC, FAN PC, JUAN KC, LIN CY, YANG HY, KAO KC, FANG JT, YANG CW, CHANG SW, CHEN YC. Acute respiratory distress syndrome with and without extracorporeal membrane oxygenation: a score matched study. Ann Thorac Surg. 2015; 100: 458–464.

16. WU MY, LIN PJ, TSENG YH, KAO KC, HSIAO HL, HUANG CC. Venovenous extracorporeal life support for posttraumatic respiratory distress syndrome in adults: the risk of major hemorrhages. Scand J Trauma Resusc Emerg Med. 2014; 22:56.

22. JACOBS JV, HOOFT NM, ROBINSON BR, TODD E, BREMNER RM, PETERSEN SR, SMITH MA. The use of extracorporeal membrane oxygenation in blunt thoracic trauma: a study of the Extracorporeal Life Support Organization database. J Trauma Acute Care Surg. 2015; 79: 1049– 1054.

17. WU SC, CHEN WT, LIN HH, FU CY, WANG YC, LO HC, CHENG HT, TZENG CW. Use of extracorporeal membrane oxygenation in severe traumatic lung injury with respiratory failure. Am J Emerg Med. 2015; 33: 658–662.

23. GEORGE WY NG *, HENRY J YUEN, KC SIN, ANNE KH LEUNG, KW AU YEUNG, KY LAI. Clinical use of venovenous extracorporeal membrane oxygenation. Hong Kong Med J 2017; 23: 168–76

18. GRAY BW, HAFT JW, HIRSCH JC, ANNICH GM, HIRSCHL RB, BARTLETT RH. Extracorporeal life support: experience with 2,000 patients. ASAIO J. 2015; 61: 2–7.

24. KAREEM BEDEIR, MBCHB, MS, RAGHU SEETHALA, MD, MSC, AND EDWARD KELLY, MD, Boston, Massachusetts. Extracorporeal life support in trauma: Worth the risks? A systematic review of published series. J Trauma Acute Care Surg : 2017 Feb; 82 (2): 400-406.

19. NOAH MA, PEEK GJ, FINNEY SJ, GRIFFITHS MJ, HARRISON DA, GRIEVE R, SADIQUE MZ, SEKHON JS, McAULEY DF, FIRMIN RK, HARV EY C, CORDINGLEY JJ, PRICE S, VUYLSTEKE A, JENKINS DP, NOBLE DW, BLOOMFIELD R, WALSH TS, PERKINS GD, MENON D, TAYLOR BL, ROWAN KM. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A (H1N1). JAMA. 2011; 306: 1659– 1668.

25. BRYNER, COOLEY, COPENHAVER et al. Two decades' experience with interfacility transport on extracorporeal memThorac Surg. 2014 brane oxygenation. Ann Oct;98(4):1363-70. doi: 10.1016/j.athoracsur.2014.06.025. 26. https://www.elso.org/ Registry/SupportDocuments/CenterI DList.aspx

20. PEEK GJ, MUGFORD M, TIRUVOIPATI R, WILSON A, ALLEN

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Is your Government Prepared for the I l ll Threat? Pandemic Influenza (Flu)

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Mass Casualty Management during UN Mission in Mali: An Evaluation. By X. YU∑, X. CAO∏, S. HANπ and G. BI∫. P.R. of China

Xuan YU Colonel, PhD, Associate Professor Xuan YU was born on January 1st, 1982 Colonel YU spends a number of years researching on military medical support management. His occupational specialties include military mobile medical unit training, military medical exercise planning, medical logistic management and medic training. He was appointed as a medical staff officer in MINUSMA, an ongoing UN Peacekeeping Mission in Mali, from October 2013 to October 2014. He participated several international medical exercise and exchange in recent years, such as ASEAN Military Medicine - Humanitarian Assistance and Disaster Relief Exercise 2016 in Thailand, China-German “Combined aid 2016” medical field exercise, and “Cobra Gold 2018” in Thailand.

RESUME Evaluation de la prise en charge des pertes massives lors de la mission des Nations Unies au Mali. Introduction : Lors de la survenue de pertes massives dans les opérations de maintien de la paix des Nations Unies, les ressources peuvent être insuffisantes, avec comme conséquence l’augmentation de la morbidité et de la mortalité. Tous les éléments médicaux doivent se préparer à gérer des pertes massives dans toute la zone de la mission. Les situations doivent être anticipées et les ressources allouées au début de chaque mission, en coordination avec les plans d’opération et de sécurité de la mission. Description : La mission intégrée de stabilisation des Nations unies au Mali (MINUSMA) a été mise en route à l’issue de la résolution 2 100 du Conseil de Sécurité des Nations Unies du 25 avril 2013. Les partenaires internationaux au Mali et dans les pays limitrophes sont confrontés à un environnement sécuritaire détérioré et très dangereux avec de fréquentes attaques des organisations terroristes contre le personnel des Nations Unies et des autres forces. La MINUSMA a enregistré un nombre de pertes croissant. Elle fournit un soutien humanitaire à toutes les forces. Tous les éléments médicaux de la MINUSMA déployés dans la zone ont mobilisé toutes les ressources disponibles pour fournir des secours depuis les postes de premier secours et les points de rassemblement des blessés dans la zone tampon. Le triage a aussi son importance avant l’évacuation par route ou par air vers les services des Nations unies ou des associations non gouvernementales. Le traitement fourni sur place se limite à des soins de base et de sauvetage. L’évacuation aérienne et les soins d’urgence médicaux et chirurgicaux sont organisés par la direction des opérations et l’hôpital de niveau II. Les évacuations secondaires sont également planifiées. Résultats : Tous les éléments médicaux de la zone ont été inclus dans le plan. Ils ont tous été mobilisés et les moyens d’évacuations ont été prépositionnés. Les équipes d’évacuation aériennes (AMET) des hôpitaux de niveau II ont été mises en alerte. Le soutien des forces françaises a été demandé pour augmenter la capacité de secours de niveau I, les moyens d’évacuation aérienne et le soutien chirurgical de niveau II. Les équipements techniques, les véhicules de transport et les ambulances, les lits, les tentes, les housses mortuaires ont été mis en commun. Conclusions : Des plans de contingence doivent être préparés à tous les niveaux depuis les équipes de terrain j usqu’au quartier général de la mission en passant par les commandements des contingents, et les commandements de secteur. Les facteurs de risque, les menaces potentielles, le regroupement des éléments médicaux, les zones de responsabilité, les tâches individuelles, les zones de prise en charge des blessés, les voies d’évacuation, l’approvisionnement médical et la coordination de tous les participants doivent tous être pris en compte. Si les lacunes peuvent être corrigées comme le suggère cet article, le soutien médical de la MINUSMA pourra gagner en efficacité. VOL. 92/1

KEYWORDS: Peacekeeping Operation, Mass Casualty, Contingency Plan. MOTS -CLÉS : Opération de maintien de la paix, Pertes massives, Plan de contingence. International Review of the Armed Forces Medical Services

Revue Internationale des Services de Santé des Forces Armées

In 2012, rebel groups from various backgrounds had driven Malian government forces out of the north of Mali, and by early 2013 they threatened even the capital, Bamako, in the south. By the time that the United Nations Multidimensional Integrated Stabilization Mission in Mali (MINUSMA) was initiated on 25 April 2013 by UN Security Council Resolution 2100 to stabilize the country, a French led intervention (Serval Operation) had led to the recapture of the main northern cities from the rebels. MINUSMA was officially deployed on 1 July 2013. In order to achieve its mandates, MINUSMA has been working together with the Malian government and its security and defense forces, the French forces, the European Union Training Mission (EUTM), UN agencies, the Group of Five for the Sahel, the humanitarian community in Mali, and a range of other local and regional organizations. Given the particularly fragile security situation and activity of armed groups, the mission operates under robust rules of engagement.

in northern Mali, relating to language barriers, heat, sandstorms, housing and fever are relevant to all foreign troops in Mali. International security partners in Mali and the surrounding countries have to deal more directly with a highly dangerous and deteriorating security environment, with frequent attacks by extremist organizations on UN personnel and other foreign forces. MINUSMA has seen a seen a growing number of fatalities. The fatalities may serve as a warning to all TCCs of the increasing dangers their troops face in the mission. MINUSMA is the UN’s most dangerous peacekeeping mission, with 169 peacekeepers killed out of a force of about 11,000 as of July 2018. The local/national medical facilities in Mali are rudimentary to the most and unable to support the urgent and more specialized medical needs of casualties that stem from the incidents and/or the prevailing conditions. As MINUSMA is a multidimensional mission with a large humanitarian component, humanitarian assistance is part of its mandate as well. This has proven to be a challenging task. The increasing number of attacks by insurgents in Mali has brought greater risks for the humanitarian community, and casualties among all the people. MINUSMA medical facilities have already been confronted with mass casualty situations, such as unrest in the North, ambush to UN convoy, attack to UN camp, and explosion in Malian camp.

BACKGROUND INFORMATION 1 INTERNATIONAL PARTICIPATION IN MINUSMA MINUSMA’s main headquarters and force headquarters are in Bamako, the capital city of Mali. Civilian and police regional offices are being set up in Gao, Timbuktu, Mopti and Kidal, while military sector headquarters are being established in Gao, Timbuktu and Kidal (2014), which are the command centers for the mission’s military personnel. So far, MINUSMA has an authorized strength of 15,209 uniformed personnel, of which 13,289 military and 1,920 police. However, in April 2018 the mission had not yet reached full deployment. 57 UN partner nations, such as Burkina Faso, Canada, Chad, China, Bangladesh, Germany, and Egypt, have send troops. But the gap of troops was long left yet been filled. MINUSMA is about armored vehicles, helicopters short of fulfilling its needs, and that troop contributing countries (TCCs) had also been asked to try to fill the equipment gap.

MINUSMA MEDICAL The size of the country, the remote and land-locked areas where we are deployed and poor and insecure road networks continue to pose significant challenges for medical support to MINUSMA’s peacekeeping operations and other humanitarian assistance operations.

1 MEDICAL MANAGEMENT OF MASCAL MINUSMA medical personnel in the provision of medical services may encounter incident where the number, severity or type if casualties, or by its location, requires extraordinary resources, or where the capacity of the facility is exceeded.

China is currently contributing military capabilities to UN peacekeeping operations in Asia and Africa. China’s contribution to MINUSMA since 2013 includes a force protection company, a construction engineer company and a level 2 hospital. There are also eight Chinese staff officers working both in Force Headquarter and Sector East Headquarter. China is the largest MINUSMA contributor among the Permanent members of the United Nations Security Council.

The existing medical support for the MINUSMA is split over different locations. For example, there is Level I ∑ Colonel, Department of Health Services, Army Medical Training Base, Army Medical University, China. ∏ Captain, Department of Health Services, Army Medical Training Base, Army Medical University, China.

As the mission consists of a range of different nationalities and cultures, with different norms, values, and work ethics, this has often led to problems related to cross cultural issues and even misunderstandings.

π Senior Colonel, Department of Health Services, Army Medical Training Base, Army Medical University, China. ∫ Colonel, Department of Health Services, National Defense University, China.

2 THE DETERIORATION OF THE SECURITY SITUATION

Correspondence: Colonel Guanyuan BI Department of Health Services, College of Joint Services, National Defense University No. 23 Taiping Road, PRC-100868 Beijing, P.R. China Email: daihong0416@sina.com

Except Malian Defense Forces and MINUSMA, there are other forces, including the European Union Training Mission, French Operation Barkhane, and the Group of Five for the Sahel. The operational challenges for peacekeepers have been substantial. Many of the challenges

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MINUSMA MASS CASUALTY MANAGEMENT

Medical Staff Team (Chief Medical Officer, Force Medical Officers)

MINUSMA Crisis Management Team

Temporary Morgue

Security Section

Military Mass Casualty Site

Stabilization in the nearest UN LI Hospital • Referral

First Aid Triage

Police AMET AMET

Others resources • Staff with First Aid Skill • Engineering and Transport Equipment

AMET

Bamako Private UN Contracted Hospital

Sector UN LII Hospital

AMET

Dakar Contracted LIII Hospital

Upon receiving the order of support MASCAL situation, Level II hospital activates the emergency response system and dispatches one or more forward medical teams (FMTone doctor, one nurse and one paramedic who is also the driver of the ambulance). At the scene, the FMT will set up First Aid Post and will continue triage as well as initial treatment of casualties.

Health Care facility in every Sector East contingent in Gao, Menaka and Ansongo. The helicopter and fixed wing Air casualty and medical evacuation (CASEVAC/MEDEVAC) service base is deployed at Gao airport. In the super camp, which is also near the Gao airport, there is a Chinese Field Hospital (Level II). There are also some Aero Medical Evacuation Teams (AMET) in Chinese Level II hospital and the Netherlands contingent. In some contingents, nurses can assist in CASEVAC/MEDEVAC. French forces can also provide Level II medical service and Aero Medical Evacuation service in support of MINUSMA operations. Level III medical service is contracted with a Dakar hospital, which is in Senegal outside of Mali.

2.3 LEVEL II At the same time, the rest of Level II hospital will be on stand-by and be ready to send additional resources and receive casualties. Due to the distances and operation consideration in theatre, it might take several hours or one night to evacuate the casualties from Level I to Level II hospital. Level II is the first level where surgical expertise and facilities are available. It is to provide second line health-care, emergency resuscitation and stabilization, lifesaving, surgical interventions and basic dental care. If indicated, travel of an accompanying AMET may be authorized to evacuate the patient to various other places within or out of the mission.

2 MEDICAL FACILITIES 2.1 AT THE SCENE In normal condition, an isolated military contingent contingents will have the presence of the physician with an ambulance at the workplace, fast and efficient medical intervention in case of an incident, and transport of wounded persons to the adequate medical institution, such as Battalion Level I or Level II hospital. In case of MASCAL, other military or police contingents nearby can also provide Level I service to the affected peacekeepers or other personnel at the Scene.

2.4 LEVEL III Level III service could be sought in the neighboring country Senegal or in the troop contributing countries according to UN-medical standard.

3 MEDICAL STAFF OFFICER TEAM ON MATTERS OF MEDICAL EVACUATION

2.2 LEVEL I VOL. 92/1

3.1 CHIEF MEDICAL OFFICER and FORCE MEDICAL OFFICER

Level I provides first line primary health care, emergency resuscitation, stabilization and evacuation of casualties to the next level of medical care.

International Review of the Armed Forces Medical Services

The Chief Medical Officer (CMO) and the Force Medical

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MINUSMA LII HOSPITAL

medical response timelines, referring to CASEVAC/ MEDEVAC. In order to effectively address the first 10 minutes from the onset of injury or illness, training for MINUSMA troops and medical personnel is ongoing. UN Headquarters is also working on the development of UN specific First Aid training material, which will be delivered to all Member States as a UN Medical Standard to be incorporated in the Pre-deployment Troop Training Material to streamline the quality of first aid delivered in UN field Missions. A regular in-mission training program, with the training plan targeted at the maintenance and standardization of core skills and procedures, should also be established.

2 COOPERATION officer (FMO) are responsible for mission medical evacuation plans with special emphasis on the integration with air assets, maintain a roster of medical officers in the mission to support air-ops in the execution of aeromedical evacuations inside mission or outside mission.

3.2 MEDICAL STAFF OFFICER both in Force HQ and Sector HQ Under the guidance of the CMO and FMO, the Medical Staff Officer (MSO) is responsible for the day-to-day implementation of the mission plan for aeromedical evacuations, offers day-to-day advise on aero CASEVAC/MEDEVAC issues, supervises in-mission aeromedical evacuations, is responsible for ongoing training to maintain and develop the aeromedical evacuation capabilities in the mission, is responsible for aeromedical evacuation exercises in the mission, is the medical point of contact for MOVCON and Air Ops.

3.3 INTERNATIONAL COORDINATOR An International coordinator (IC) is deployed in Dakar, facilitates efficient medical administrative, logistics and liaison support to all MINUSMA civilian, military and police components and/or any other authorized entities in the execution of the Letter of Assist between MINUSMA and the Government of Senegal, in support of MINUSMA operations and fulfilment of its Mandate. During CASEVAC/ MEDEVAC, the IC will enhance coordination of process between MINUSMA and Senegal, such as landing at airports, appro priately equipped ambulance and transfer from aircraft, and readiness of receiving hospital and specialists. In conclusion, contingency plans, which were prepared at each level, from the Team Site through the Contingent HQ, Sector HQs and up to Mission HQ level, have played an important role on matters of medical support in mission.

THE WAY FORWARD: RECOMMENDATIONS TO UN MISSION

Significant efforts are being made to strengthen the Mission Medical Support Plan, equipment and personnel gaps identified in Mission Medical Facilities. As should be expected, a number of challenges have surfaced when integrating TCCs capabilities into MINUSMA. European TCCs have provided key logistical and aircraft assets such as C-130s, C-160s, and Chinook helicopters. These have significantly increased mission mobility and ensured the availability of adequate casualty and medical evacuation capabilities. The Dutch work closely with the Bangladeshi, Chinese, and other troops in Gao. The ability of the Dutch Apache helicopters to provide close air support to non-European TCC units operating on the ground is limited by the lack of a common language, inadequate communications equipment of ground troops, or an unawareness of common protocol for signaling positions. We found a need for increased partnership among TCCs in MINUSMA. The potential of partnerships is great but still largely untapped. Communication and collaboration between MINUSMA TCCs and other forces still need significant strengthening to make the mission more operationally effective.

3 BUDGETARY One specific problem with the Director of Mission Support (DMS) control over both civilian and military assets is the budgetary considerations that are part of decisions to deploy one type of asset over another. Civilian air assets are contracted such that they are paid in more or less a fixed amount regardless of usage, whereas military assets are generally paid depending on the amount of flight hours used. As such, it makes financial sense for a DMS to employ a civilian helicopter over a military one if possible, which potentially leads to underuse (and less reimbursement) of the TCC air assets. Most UN civilian rotary wing flights are not capable of night CASEVAC/ MEDEVAC, which might delay some evacuation operation. While some military air assets can conduct the evacuation operation, if the security risk is acceptable. Contracts should be redesigned.

CONCLUSION

1 TRAINING MINUSMA’s vast area of operations and the austere environment present unique challenges with regard to the implementation of the 10- 1-2 international emergency

International Review of the Armed Forces Medical Services

If addressed in constructive ways, as has been the case in many instances so far, then the system described in this paper can help MINUSMA become more effective

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Conclusions: Contingency plans should be prepared at each level, from the Team Site through the Contingent HQ, Sector HQs and up to Mission HQ level. Risk factors, potential threats, grouping of medical units, areas of responsibility, individual tasks, casualty holding areas, evacuation routes, medical supplies, and coordination with other stakeholders should be all taken into considerations. If some defects could be addressed in constructive ways as suggested in the paper, MINUSMA medical support would become more effective.

while also helping the UN peacekeeping system as a whole better address today’s medical challenges.

ABSTRACT Introduction: During mass casualty situation in UN peacekeeping operations, sufficient resources are unavailable to manage the multiple casualties, thereby increasing the likelihood of morbidity and death. All medical units have to prepare for mass casualty incidents within the Mission area. Contingencies must be planned and resources allocated at the beginning of a new mission, and coordinated in line with the Mission’s operational and security plans. Content: The United Nations Multidimensional Integrated Stabilization Mission in Mali (MINUSMA) was established by Security Council resolution 2100 of 25 April 2013. International security partners in Mali and the surrounding countries have to deal more directly with a highly dangerous and deteriorating security environment, with frequent attacks by extremist organizations on UN personnel and other foreign forces. MINUSMA has seen a seen a growing number of fatalities. MINUSMA provides humanitarian assistance to the casualties among all the people. All MINUSMA medical units deployed in affected area mobilized all their available resources to provide immediate support, including establishing First Aid posts and casualty collection points at the buffer zone between the conflicts. Triage was important here to establish priority for treatment, and for evacuation by land and air to UN, local and NGO medical facilities. Treatment provided at the site was limited to Basic Life Support and casualty resuscitation. Aero Medical Evacuation support and emergency care and surgery were organized and provided in Sector HQ and Level II hospital. Further evacuation was also organized according to the plan.

Note The opinions expressed in this article are solely those of the authors and do not necessarily represent the official views of the Chinese PLA. REFERENCES 11. United Nations Department of Peacekeeping Operations and Department of Field Support, United Nations Peacekeeping Operations: Principles and Guidelines, New York, 2008. 12. United Nations Department of Peacekeeping Operations and Department of Field Support, Authority, Command and Control in United Nations Peacekeeping Operations, New York, 2008. 13. United Nations Department of Peacekeeping Operations, General Guidelines for Peacekeeping Operations: principles and Guidelines, New York, 2008. 14. United Nations Department of Peacekeeping Operations and Department of Field Support, Medical Support Manual for UN Field Missions, New York, 2015. P167-177. 15. Min YU, Rui LI and Lei QIU. Overcoming New challenges in Medical Support for UN Peacekeeping Operations. International Review of the Armed Forces Medical Services. 2018, 91 (1): 21-28. 16. Isaline BERGAMASCHI. MINUSMA: initial steps, achievements and challenges. Norwegian Peacebuilding Resource Center. September 2013. P1-4.

Results: All MINUSMA medical units in affected areas were enrolled in the plan. All medical units had been mobilized and evacuation assets were prepositioned. Full Aero Medical Evacuation Team (AMET) capacities from UN Level II hospitals had been prepositioned in readiness mode. French Forces support had been solicited and would secondarily augment UN support through Level I emergency services, Aero Medical Evacuation support and Level II surgery Services. Engineering equipment, transport vehicles and ambulances, body bags, transfer cases, beds and tents were collaborated inter sectional.

17. Adam C. SMITH. European Military Capabilities and UN Peace Operations: Strengthening the Partnership. Center for International Peace Operations. October 2014. P1-7. 18. John KARLSRUD and Adam C. SMITH. Europe’s Return to UN Peacekeeping in Africa? Lessons from Mali. International Peace Institution. July 2015. P1-16. 19. http://minusma.unmissions.org/ 10. MINUSMA. SOP of MINUSMA medical service in GAO L-II hospital. 2017. P15-21.

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International Review of the Armed Forces Medical Services

Revue Internationale des Services de Santé des Forces Armées

M IS S NOT H I NG. FA ST E R. I N T RA U MA & FO R ENS IC PAT HO LO GY

Disaster victim management from mass shootings, explosions, earthquakes, and other unfortunate massive-scale catastrophes can be addressed at life-saving speeds.

FULL-BODY

HIGH-SPEED

LOW RADIATION

The�effectiveness�and�high�speed�of� imaging�dramatically�reduces�the� resuscitation�time�of�patients�with� major�injuries,�allowing�imaging�of� a�large�number�of�patients�in�a�very� short�time.1

The�remarkable�detection�rate�for� treatment�and�speed�at�which�the� whole�body�can�be�evaluated�are� advantages�in�the�primary�survey�of� acute�trauma�patients.2

Radiation�emission�and�scatter� are�significantly�lower�compared� to�conventional�X-ray�equipment� (average�6%�of�conventional� exposure1,�0.12�mGy�entrance�dose3 ).

CLINICAL AND OPERATIONAL BENEFITS OF THE LODOX FULL-BODY IMAGING SOLUTION: •� •� •� •� •� •�

X-ray�of�the�entire�body�in�13�seconds. All�answers�are�presented�simultaneously.� Improved�safety�for�staff�and�patients. High�image�quality�reduces�chances�of�missing�vital�information. Throughput�in�a�forensic�facility�is�increased� by� reducing�the�time� required� for�full�body�examination.4,5� CE-mark,�FDA�approved,�ISO�13485�&�MDSAP�certified.

REFERENCES: 1.� 2.� 3.� 4.� 5.�

Boffard�KD,�Goosen�J,�Plani�F,�Degiannis�E,�Potgieter�H.�The�use�of�low�dosage�X-ray�(Lodox/Statscan)�in�major�trauma:�comparison�between�low�dose�X-ray�and�conventional�X-ray�techniques.�J�Trauma�2006;60(6):1175-1183. Chen�RJ,�Fu�CY,�Wu�SC,�Wang�YC,�Chung�PK,�Huang�HC,�Huang�JC,�Lu�CW.�Diagnostic�accuracy,�biohazard�safety,�and�cost�effectiveness�-�the�Lodox/Statscan�provides�a�beneficial�alternative�for�the�primary�evaluation�of�patients�with�multiple�injuries.�J�Trauma� 2010;69(4):826-830. Irving�BJ,�Maree�GJ,�Hering�ER,�Douglas�TS.�Radiation�dose�from�a�linear�slit�scanning�X-ray�machine�with�full-body�imaging�capabilities.�Radiat�Prot�Dosimetry�2008;130(4):�482-489. Knobel�GJ,�Flash�G,�Bowie�GF.�Lodox�Statscan�proves�to�be�invaluable�in�forensic�medicine.�S�Afr�Med�J�2006;�96(7):593�-594 Douglas�TS,�Fenton-Muir�N,�Kewana�K,�Ngema�Y,�Liebenerg�L.�Radiological�findings�at�a�South�African�forensic�pathology�laboratory�in�cases�of�sudden�unexpected�death�in�infants.�S�Afr�J�Radiol�2012;�16(1):�4-6

www.lodox.com

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The Rehabilitation and Treatment of Scar by Laser Technology.* By H. CAI, Y.X. WANG, Z.J. XING, P. SUN, Q.Y. XU, A.Q. JU and W. LIU. P.R. China

Hong CAI Dr. CAI has completed her PhD and MD at the age of 32 from Chinese PLA Medical University and postdoctoral studies from Chinese Air Force Medical University. She is working in Dermatology hospital, Air Force Medical Center, PLA since 2008. She was the chief of Laser Medicine Center, and was associate professor of Medicine. She has published more than 30 papers in reputed journals and has been serving as an editorial board member of repute.

RESUME Traitement des cicatrices hypertrophiques par technique laser. Une cicatrice hypertrophique résulte d’une prolifération excessive lors du processus de réparation; son incidence est élevée et elle survient souvent après des traumatismes, des brûlures ou des inflammations post-opératoires. Lors d’une revue annuelle, il a été relevé que l’incidence des brûlures avait été de 18 % chez les Américains lors de la guerre en Irak. Dans ces cas, la destruction de tissu cutané représente 43 %. Une cicatrice hypertrophique en est la conséquence la plus fréquente. Cette cicatrice et la rétraction sont à l’origine de différents degrés de déformité et de troubles fonctio nnels. Parmi les 745 000 soldats américains ayant combattu en Afghanistan et en Irak et qui ont été touchés par une affection de longue durée, 23 % soufraient d’une blessure de la face. Ces cicatrices peuvent être la cause de troubles psychologiques et physiologiques et altérer la qualité de vie du patient. Les méthodes de traitement conventionnelles ne donnent pas satisfaction. Ces dernières années, a vec les progrès dans la technologie laser et la capitalisation d’expériences cliniques, le laser est devenu une méthode importante de traitement des cicatrices hypertrophiques. Elle peut améliorer la cicatrice en détruisant les vaisseaux sanguins et en stimulant le remaniement des fibres collagène de la cicatrice. Les techniques récentes de laser fractionné CO2 et de laser à colorant pulsé représentent des ressources sûres et efficientes pour le traitement des cicatrices.

KEYWORDS: Laser, Injury, Scar, Rehabilitation, Treatment. MOTS -CLÉS : Laser, Blessure, Cicatrice, Réhabilitation, Traitement.

INTRODUCTION

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disability subsidies of which 23% had facial damage. 90% of the soldiers with facial damage injuries had suicidal tendency. Therefore, the physiological and psychological

Burn wounds are common both in wartime and in peacetime. According to Professor Geoffrey, an American medical expert on critical medicine in the annual medical review, the US military casualties in the Iraq war were 18.8%1 of which the skin soft tissue damage was the primary, about 43%. The scar formation and contracture are the ultimate end points for skin soft tissue injury. As the scar formation and contracture can cause different degrees of malformation and dysfunction, it is reported that 745000 American soldiers after the war in Iraq and Afghanistan applied for life-long

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Correspondence: Dr CAI Hong, PhD, MD Department of Dermatology Air Force medical Center, PLA No.30 Fucheng Road Haidian District PRC-100142 Beijing, P.R. China Phone: 86-015116908928 E-mail: ch1031@163.com * Presented at the 42nd ICMM World Congress on Military Medicine, New Delhi, India, 19-24 November 2017.

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effects of scar are important components of modern military rehabilitation medicine. The prevention, control and treatment of hypertrophic scar after the war would not only preserve the physiological function of the injured skin and joints to the maximum limit, but shall also have a remarkable medical, aesthetic and psychological effect on patients 2.

repair the damaged epidermis quickly, initiate the tissue healing mechanism, at the same time stimulates the proliferation of the collagen rapidly and promotes the proliferation and remodelling of the fibroblast simultaneously to achieve the purpose of improving and treating the appearance of scar5.

c. Lasers promote biochemical cascade effect

The existing methods of treatment include drugs, silica gel, radiation, laser, filling, surgery and so on. However, there are still lack of practical and effective treatment strategies at present, for the complex and diverse pathogenesis and morphology of scar3. Ginsbach used argon ion laser in the treatment of hypertrophic scars for the first time in 1978, and achieved satisfactory results. Since then on, laser treatment have been used in the field of scar repair to provide treatment options for vascular hyperplasia, pigmentation, and texture restoration of scars, which have achieved good results. According to the classification and clinical evaluation of scars, different clinical laser equipments can be used for treatments.

LASER TREATMENT OF SCAR

According to a series of basic researches, laser treatment will not only perforate intermittently in the scar. The key is to generate certain amount of heat. Controllable thermal damage can reach the deep scar tissue through each small and deep hole, promote the expression of p16INK4a of the fibroblast, inhibit the cell division and proliferation and promote biochemical cascade effects, including the up-regulation of heat shock proteins (HSP72, HSP73, HSP47), selective inhibition of collagen synthesis of scar fibroblasts, and the inhibition of the expression of type I and type III procollagen mRNAs. The ratio of the two decreases after 6 months of treatment, and the expression of metalloproteinase-1 (MMP-1) is significantly increased, but the result of the repair is related to the number of skin appendages remaining in the tissue6, 7.

The mechanism of laser treatment of scar is not very clear at present.

LASER TREATMENT FOR SCARS Currently, there are many kinds of lasers used to treat scars. According to the different treatment periods, we can divide them into different period. Lasers that block out blood vessels during the early period, lasers that inhibit fibrous tissue’s hyperplasia and promote apoptosis during the progressive period and lasers that Eliminate convex scar tissue, promote collagen regeneration and reconstruction during the mature period. Due to the different laser devices and wavelengths, the mechanism of action may not be unilateral, or combined with several aspects to treat scars.

a. The mechanism of laser treatment of early hypertrophic scar The theory of selective photo thermal effect lays the theoretical foundation for laser specific treatment of the rich blood vessels in the scar. In the early scar tissue, there are a large number of new blood vessels and hemoglobin becomes the target tissue. According to the photo thermal absorption spectrum, the selective wavelength laser can be selectively absorbed by more hemoglobin. The final closure of the neovascularization and the decrease of tissue blood supply resulted in hypoxia, leading to the apoptosis of fibroblasts, the decrease of collagen secretion and the degradation of collagen fibers. Laser treatment of blood vessels in the scar has become the mainstay of early application of laser to inhibit scar formation4.

a. Pulsed dye laser (PDL) Early scars appear red, and have plenty of blood vessels, according to the process of damage repair. Fibroblasts begin to proliferate and deposit within six months after scar formation. PDL treatment of early hypertrophic scar can improve the height, erythema and flexibility of the scar8. However, the mechanism of PDL in improving the scar is not very clear. Some scholars believe that PDL selectively destroys the superficial micro vessels of the scar and targets the hemoglobin as the target matrix. Energy is specifically transmitted to the capillaries in the scars, causing the blocking of blood vessels, the degeneration and necrosis of endothelial cells, and the decrease of the number of capillaries, which increases the degree of ischemic and hypoxic scar tissue, increases the collagenase release, and increases collagen degradation. At the same time, the microenvironment of scar tissue is changed, and the functional state of fibroblasts is inhibited, thereby reducing collagen synthesis9. Some scholars also postulate that PDL can reduce the expression of transforming growth factors (TGF-ß), which inhibits the proliferation and division of fibroblasts and reduces collagen deposition10.

b. The mechanism of "micro peeling" The fractional laser technology integrates “micro peeling” and “bridge healing” and fully utilizes the features of its peak energy and small thermally induced damage. It generates multiple micro-damage zones by specific lasers, which can accurately and quickly vaporize the tissue. The fractional laser technology overcomes the shortcomings of the traditional methods which caused serious damage to the surrounding tissues. Firstly, it can penetrate scar deeply by adjusting the therapeutic parameters. Laser produces enough thermal damage, leads to apoptosis of fibroblasts, and initiates regenerative repair procedures and activates epidermal stem cells. Secondly, laser’s target is water, and the main component of skin is also water. So, laser can penetrate the epidermis directly to the deep layer of the dermis, and cause damage repair reaction. It can

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consensus paper on scar treatment in 201414. They believed that ultra-pulsed CO2 laser can be used to loosen and soften contracted scar tissues, following the treatment principle of “high energy and low density, short pulse width and small spot”, and it can be combined with the early intervention of the PDL to achieve good curative effect.

In addition, it is also believed that PDL stimulates the mast cells to release the histamine and interleukin to affect the metabolism of collagen, and heats the collagen fibers to break the disulfide bonds, causing the rearrangement of collagen fibers. PDL treatment should be repeated with low-energy multiple treatment, treatment interval of 1 month. Usually the erythema of scars can ease 50% after two sittings of treatment. The most common side effect is the purpura, which can appear after surgery and usually regresses within 7 to 10 days. Edema is also very common, and the duration is generally less than 48 hours.

c. Non-ablative fractional laser Non-ablative fractional laser mainly includes Nd: YAG lattice lasers (1320nm, 1440nm) and Er: Glass lattice lasers (1540nm, 1550nm). The targets of non-ablative fractional lasers are also water, but the generating beams do not form skin gasification pits, but they just merely cause thermal denaturation of the skin’s dermis. At the same time, the non-ablative fractional laser therapy is a non-invasive treatment, and a large number of literature reports suggest that it not only can improve the color and thickness of hypertrophic scars, but can also shorten the recovery time and reduce adverse reactions. It has been proposed to be a treatment option for hypertrophic scars at present15.

b. The ablative fractional laser The ablative fractional lasers mainly include CO2 laser with a wavelength of 10600 nm and Er: YAG laser with 2940nm. These lasers act on tissues to vaporize tissue instantly, and the skin around the gasification area causes collagen contraction after the skin is heated. The mechanism of treating scars is based on the principle of focal photo thermal effect. Fractionally arranged microscopic beams act on the skin to form a number of microscopic treatment zones (MTZs), and most of the tissues around the microscopic treatment zones remain intact. The su rrounding undamaged tissue rapidly promotes the healing of MTZs wounds by cell migration11.

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d. Other lasers Photodynamic therapy is widely used in basal cell carcinoma, Actinic Kerasotes and Bowen’s disease. Recently, photodynamic therapy has been proposed for the treatment of scars. The therapeutic mechanism is not yet clear. It can effectively reduce pruritus and pain and increase the softness of the scar. The mechanism of scar formation is related to scar fibroblasts, extracellular matrix and various cytokines, which together regulate fibroblast transformation, proliferation, metabolism and apoptosis. Photodynamic therapy can lead to the damage of the endoplasmic reticulum and mitochondria in fibroblasts, and there are many cross points after the damage, which mutually regulate cell death. Therefore, photodynamic therapy may become a better adjuvant therapy option for hypertrophic scars16.

The CO2 fractional laser has a deep penetration, and the thermal damage zone of the skin around the gasification area is wider. The long term effect is the increase of type I collagen and elastic fibers in the treated tissue, and the rearrangement of the abnormal structure in the scar and reconstruction of the normal skin structure12. After treatment, slight decrustation occurs. The incidence of pigmentation is higher than that of the lattice erbium laser and the treatment of superficial scars can be significantly improved over time. Ozog7 utilized the CO2 fractional laser to treat mature burn scars. After 3 sessions of treatments, appearance of the subjects was improved, collagen structure was significantly improved, expression of type III collagen was increased and the expression of type I collagen was reduced. The lattice erbium laser has a high absorption rate of water (10 to 20 times that of CO2 laser), more accurate stripping, smaller thermal damage to the surrounding normal tissue, short recovery period and low incidence of pigmentation. However, its penetration is relatively superficial. Its heating damage to areas of collagen stimulation (contraction and regeneration) is limited. So, the effect on superficial scar is significant. As we know, erbium laser lacks hemostatic function, it may cause massive skin bleeding. Jae13 applied Er: YAG lattice laser treatment for 13 patients with hypertrophic scar and CO2 laser treatment on 10 patients with hypertrophic scar. The results showed that the flexibility of the scar improved significantly after two kinds of treatments. The results indicate that scar flexibility by Er: YAG fractional lasers improved by 28.2%, while with CO2 lasers it improved by 49.8%, according to Vancouver scar scale (VSS) average score. There are eight famous American experts such as Anderson who wrote a

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ADVERSE REACTIONS FOLLOWING LASER TREATMENT OF SCARS Most studies did not report serious adverse reactions. The reported adverse reactions mainly include: pain and postoperative erythema, blisters and exudation, which are all related to the dose. All of adverse reactions can be relieved after nursing care and symptomatic treatment, combined with external use of burn ointment and other external drugs, which can greatly reduce the occur incidence of adverse reactions17.

CONCLUSION Although the mechanism of laser treatment of hypertrophic scars and keloids is not yet very clear, but there are many literature and clinical practice reports that provide strong supportive evidence that through selective photothermic effects, it can play a role in the prevention and treatment of scars18. The key to curative effect of laser treatment of pathological scars is to choose the right laser type and therapeutic dose. The

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Child, f emale, 12 years old, f acial scar af ter trauma. Figure 1: Bef ore laser treatment. Figure 2: Af ter laser treatments. Treatment parameters, Combo mode (Fractional deep combined superf icial treatment mode, superf icial mode: 80-100mJ, density 40-50%, Deep mode: 10-12mJ , Density 15-20 %), treatment interval is 3 months.

treatment of erythema-proliferative scars is mainly to inhibit proliferation, and mainly to choose PDL laser or LPDL laser. For the treatment of mature scars, the purpose is mainly to improve the appearance of the scars and the resulting dysfunctions. Choosing CO2 lasers, Er: YAG lasers which have the similar treatment principles and effects, can promote the remolding of disorderly arranged collagenous tissues and can obtain better therapeutic effect. Acknowledgements

lifelong disability allowance, damaged facial injuries accounted for 23% of them. Scars of skin can cause serious psychological and physiological morbidity to the patients and affect the patients’ quality of life adversely. Traditional treatment methods are not satisfactory. In recent years, with the advances in laser technology, as well as the accumulation of clinical experiences, laser technique has become an important method of scar treatment. It is capable of revising the pathological scar by destroying blood vessels and stimulating collagen remodelling within the scar.

We would like to thank Dr. Jiang Bei Cao for his support of t his research. We gratefully ac knowledge the members of the Dermatologic Department at the Air Force General Hospital for their technical support. This research was supported by a grant from the National Natural Science Foundation of China (Contract grant number: 81301386).

The new modality of fractional CO2 laser and dye laser is an effective and safe strategy for the therapy of scars.

ABSTRACT

11. SHUMAKER PR. Laser treatment of traumatic scars: a military perspective [J]. Semin Cutan Med Surg. 2015; 34 (1): 17-23.

REFERENCE

Scar tissue is the excessive proliferation in the process of wound healing. The incidence is higher, often occurs in trauma, burns, and inflammation after operation. In the annual review of medicine, it has been reported that the rate of burns have been 18% in Iraq war. In these cases the destroyed skin soft tissue injury is about 43%. Scar was the final repair end point for most of the skin soft tissue damage. Scar formation and contracture can cause varying degrees of deformity and dysfunction. According to reports on American soldiers in Iraq and Afghanistan war, of 745000 to apply for the

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12. WAIBEL JS, RUDNICK A. Current trends and future considerations in scar treatment [J]. Semin Cutan Med Surg. 2015; 34 (1): 13-16. 13. ELSAIE ML, CHOUDHARY S. Laser for scars: a review and evidence- based appraisal [J]. Drugs Dermatol, 2010,9 (11): 1355-1362. 14. AL-MOHAMADY AEL-S, IBRAHIM SM, MUHAMMAD MM. Pulsed dye laser versus long-pulsed Nd: YAG laser in the treatment of hypertrophic scars and keloid: A comparative

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randomized split-scar trial. J Cosmet Laser Ther. 2016; 18 (4): 208-212.

fractional laser provides long-term improvement of mature burn scars--a randomized controlled trial with histological assessment. Lasers Surg Med [J]. 2015; 47 (2): 141-147.

15. LEI Y, LI SF, YU YL, et al. Clinical efficacy of utilizing Ultrapulse CO2 combined with fractional CO2 laser for the treatment of hypertrophic scars in Asians-A prospective clinical evaluation [J]. J Cosmet Dermatol. 2017; 16 (2) : 210-216.

12. ANDERSON RR, DONELAN MB, HIVNOR C, et al. Laser treatment of traumatic scars with an emphasis on ablative fractional laser resurfacing: consensus report. JAMA Dermatol . 2014 Feb; 150 (2): 187-193.

16. CHESNUT C, MEDNIK S, LASK G. Hypertrophic scar treatment with intralesional triamcinolone acetonide and pulsed dye laser results in necrosis [J]. Cutis, 2014; 94 (5): E1213.

13. JAE EUN CHOI, GA NA OH, JONG YEOB KIM, et al. Ablative fractional laser treatment for hypertrophic scars: comparison between Er: YAG and CO2 fractional lasers [J]. J.Dermatol Treat, 2014,25: 299-303.

17. OZOG DM, LIU A, CHAFFINS ML, et al. Evaluation of clinical results, histological architecture, and collagen expression following treatment of mature burn scars with a fractional carbondioxide laser [J]. JAMA Dermatol, 2013,149 (1): 50-53.

14. KOIKE S, AKAISHI S, NAGASHIMA Y, et al. Nd: YAG Laser Treatment for Keloids and Hypertrophic Scars: An Analysis of 102 Cases [J]. Plast Reconstr Surg Glob Open, 2015,2 (12): e272. 15. CLAYTON JL, EDKINS R, CAIRNS BA, et al. Incidence and managementof adverse events after the use of laser therapies for the treatment of hypertrophic burn scars [J]. Ann Plast Surg, 2013,70 (5): 500-505.

18. BREWIN MP, LISTER TS. Prevention or treatment of hypertrophic burn scarring: a review of when and how to treat with the pulsed dye laser [J]. Burns, 2014,40 (5): 797-804. 19. KIM DH, RYU HJ, CHOI JE, et al. A comparison of the scar prevention effect between carbon dioxide fractional laser and pulsed dye laser in surgical scars [J]. Dermatol Surg, 2014,40 (9): 973-978.

16. H.CAI, Y.GU, Q.SUN, J. ZENG, N. DONG. Effect of hematoporphyrin monomethyl ether-mediated photodynamic therapy on hypertrophic scar fibroblasts. Photodermatol Photoimmunol Photomed, 2011, 27 (2): 90-96.

10. KARMISHOLT KE, TAUDORF EH, W ULFF CB, et al. Fractional CO2 laser treatment of caesarean section scarsA randomized controlled split-scar trial with long term follow-up assessment [J]. Lasers Surg Med. 2017; 49 (2): 189-197.

17. KIM S, CHOI TH, LIU W, et al. Update on scar management: guidelines for treating Asian patients [J]. Plast Reconstr Surg, 2013,132 (6): 1580-1589. 18. KHATRI KA, MAHONEY DL, McCARTNEY MJ. Laser scar revision: A review [J]. J Cosmet Laser Ther, 2011,13:54-62.

11. TAUDORF EH, DANIELSEN PL, PAULSEN IF, et al. Non-ablative

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2008-2018, After the Explosion of an Ammunition Stockpile... By L. NIKOLLARI∑, A. BEJLERI∏, D. VASHAπ, M. MJEDA and E. NIKOLLARI. Albania

Luan NIKOLLARI Colonel (r) Prof. Asc. Dr. Luan NIKOLLARI was born on 25.10.1957 in Përmet, Albania. EDUCATION 1972-1976: High Medical School, Pharmacy Technician. 1977-1983: University of Tirana, Faculty of Medicine, Branch GP, Tirana. 199 1-1992: 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 Hospita l “CELIO” and Study Center of Medical Research in Military Preventive Medicine, Rome, Italy. POSITION 1983-1993: Chief of Medical Se rvice Fantery Brigade in South Albania. 1993-1998: Head of Service of Preventive Medicine and Health preparation, Department of Health, General Staff of Albania Armed Forces (GSAAF), Ministry of Defense (MoD). 1999-2000: University Central Military Hospital (UCMH). Head of the Department of epidemiology. 2000-2006: Director of Medical Service Albanian Armed Forces at MoD & GSAAF. 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.

RESUME 2008-2018, après l’explosion d’un stock de munitions… Introduction : Comme tous les anciens pays communistes, l’Albanie a hérité de ses 50 ans d’un vaste arsenal de stocks d’armes et de munitions, ainsi que d’obus et de proj ectiles de différents calibres, qui mettaient gravement en danger la vie des personnes et des communautés dans les régions où ils étaient déployés. Après les années 1990, les Forces armées albanaises se sont engagées sur la voie de la transformation et de l’intégration de l’Albanie à l’OTAN. Dans ce cadre, la mise en œuvre des réformes de la défense visait à réduire et à moderniser l’Armée. Méthodes et matériel : Il s’agit d’une étude descriptive de l’expérience acquise lors d’un événement maj eur survenu dans une ancienne installation militaire désaffectée à Gërdec, le 15 mars 2008, à environ 10 km au nord-ouest de Tirana. Les munitions collectées pour la démolition ont explosé, causant un tort considérable à la santé de la population et ont appelé à l’engagement immédiat de nombreux organismes publics s’occupant de catastrophes. Résultats : Cette catastrophe a causé 26 morts et plus de 300 blessés. Plus de 60 % des blessés ont été soignés à l’Hôpital Militaire. De l’appui logistique et de l’assistance matérielle et médicale ont également été fournis par les pays alliés. Discussion : Nous avons appris de cet événement qu’il était nécessaire de réévaluer les risques et les menaces auxquels la communauté militaire et civile pouvait faire face, causés par un stock excessif de munitions. La formation et la préparation rapide des forces armées, en particulier du personnel médical militaire, sont nécessaires pour assurer une gestion efficace des catastrophes humaines maj eures. L’établissement ou la mise à j our des procédures opérationnelles standard (SOP) médicales, p our toute situation similaire à l’avenir, est nécessaire pour gérer efficacement ce type de situation. Conclusions : A présent, l’Albanie ne dispose plus de stocks excessifs ou risqués d’armes et de munitions. Par conséquent, ses efforts et ses investissements de Défense sont maintenant traités dans d’autres domaines d’intégration complète dans les structures et procédures de défense collective. Les Forces armées albanaises disposent de plans d’intervention bien définis afin de prévenir efficacement toute situation future telle que celle-ci.

KEYWORDS: Albania, Ammunition stockpiles, Explosion, Military Hos pital, Military modernization, Medical preparedness, Healthcare impact. MOTS -CLÉS : Albanie, Stocks de munitions, Explosion, Hôpital militaire, Modernisation militaire, Préparation médicale, Impact sur les soins de santé. International Review of the Armed Forces Medical Services

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INTRODUCTION

over 300 injured. More than 60% of the injured were treated in the Military Hospital. (Picture 1). Picture 1: Some view of exp losion in Gërdec on March 15, 2008, Vora-Tirana, Albania.

Albania, like all the former communist countries, inherited from its 50 years a large arsenal of weapons and ammunition stockpiles, as shells and proj ectiles of various calibers, which constituted a negative phenomenon and seriously jeopardized the lives of people and communities throughout the geography of their deployment. After the 1990s, the Albanian Armed Forces embarked on the path of transformation and integration of Albania into NATO. In this framework, the implementation of defense reforms aimed the reduction and modernization of the military. In this context, one of the transformation goals was the getting rid of the remaining excess ammunition that was being destroyed under the programs of the Ministry of Defense and partner countries. The legacy of the enormous stockpiling of military capabilities throughout the communist era has plag ued Albania for more than two decades. These stockpiles pose a security threat to our nation and the wiser region.

The main purpose in this situation was the salvation of the lives of wounded and injured people, giving first aid, stabilizing and treating at the tertiary level. The medical institution that hold the main burden and managed a large inflow of hurt people, because of its position as the closest medical facility, was the former Central Military Hospital (CMH), today Trauma University Hospital and Military Hospital, as one of the most important medical institutions in country due to its tradition, experience created over the years activity as National Trauma Center. (Picture 2).

GENERAL REMARKS From the public health point of view, the risks and threats were ranked as the following:

Picture 2: University Hosp ital Trauma & Military Hosp ital Tirana, Albania.

1. Natural risks: a) Geological (earthquakes, rocks, landslides); b) Hydrological (rivers and streams floods); c) Atmospheric (heavy snowfalls, snow storms; avalanches, wind storms, droughts); d) Biophysics (epidemics, forest fires). 2. By human origin: floods from dams damages, technological disasters. 3. Potential ecological events due to a very large number of industrial facilities and installations of communist era now completely destroyed and abandoned.

On March 15, the day of the event, even though it was the official holiday, in less than 25 minutes 100% of medical staff went at their workplaces without any official call or warning, but only concerned by the explosion echo and the media news. In less than 1-2 hours, the hospital emergency was invaded by 178 cases, 61 of which were hospitalized. (Tab.1).

However, among all these various risks and threats, a "hidden enemy " was not yet identified and discovered: risks and threats arising from the excess stocks of ammunition and explosives3 .

THE EXPLOSION OF THE AMMUNITION IN GËRDEC.

Over 98% of those injured treated in Emergency Ward had incision, crush wounds at the head, face and extremities, limb fractures, body and head contusions, burns etc. (Picture 3).

The explosion of the ammunition collected for the demolition happened at the disposal site in a disestablished former military unit in Gërdec, on March 15, 2008 at 12.15am, 10km northwest of Tirana, near the TiranaDurrës national highway, at a straightaway distance of about 3-4km from the National Airport 1.

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∑ Colonel (r) Prof. Asc. Dr, Trauma University Hospital & Military Hospital. ∏ Doctor, Trauma University Hospital & Military Hospital. π 1 Lieutenant, Trauma University Hospital & Military Hospital.

The explosion, like an atomic mushroom, in a few minutes, created a huge detriment in the health of people directly or indirectly involved in the region and urged the immediate commitment and involvement of some disaster-related state agencies such as the Ministry of Defense, Ministry of Public Order, and Ministry of Health. This disaster caused 26 deaths and

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Correspondence: Colonel (r) Prof. Asc. Dr. Luan NIKOLLARI Spitali Ushtarak Rruga “Lord Bajron” Laprakë AL-1000 Tirana, ALBANIA Phone: +355 68 40 10 141 (Mobile) E-mail: lnikollari@yahoo.it

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Tab. 1: Statistical Data, Ammunition Exp losion in Gerdec - March 2008. NO

DATA

AGE

SEX

0-14

14-30

>30

105

TOTAL

176

100

TOTAL CASES

VLC

56.2

FRACTURES

11.3

COMMOTIONS & CONTUSIONS

24.4

A RM AMPUTATION

0.5

DIFFERENT BURNS

7.3

TOTAL (2+6)

176

100

HOSPITALIZED

100

GREECE

ITALY

T URKEY

TOTAL

16.6%

EVACUATED ABROAD

Picture 3: Views of traumatized f rom the exp losion p resented to the Emergency of the Military Hosp ital.

assistance and solidarity of neighboring and other countries like, Italy, Turkey, Greece, FYROM, Kosovo and the involvement of the diplomatic corps and military attaches to this humanitarian operation.

(Views of Military Hosp ital and Emergency Room)

The Preventive Medicine Corps, part of the Military Medical Institute, provided the health insurance of the military troops engaged on search and rescue and consequences relieving operations at the site of the explosion. For this purpose, the Health Service of the Commando Forces and the Rapid Reaction Brigade (Land Force) established a field health center close to the explosion area with medical personnel, evacuation tools etc. (Picture 4) . Picture 4 .

Medical staff at the site of the exp losion.

Emergency medical staff and all other hospital departments, with unmatched dedication, professionalism, humanism and solidarity, elaborated and stabilized all the injured. The private “American Hospital" was also directly committed in providing first aid and hospitalizing the serious cases. This was highly appreciated by all the top authorities of the country and foreigners.

Medical Facility Role 1 in f ield.

Six of the most seriously injured hospitalized in Military Hospital, were transported to Thessaloniki and Ioannina Hospitals in Greece and four others to Italy. It is also worth mentioning and appreciated the support and helps coming from France, USA, Germany and Greece with medical supplies and equipment, and the

International Review of the Armed Forces Medical Services

For the health insurance of the military troops participating in the operation, in addition of the Operational Center for providing troops support, it were established

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Picture 6: Vaccination of troops with anti-tetanus vaccine and immunoglobulin.

and engaged even Field Health Centers manned with high and medium professional level personnel, with 10 beds, ambulances as well as additional supporting personnel and medical evacuation means and capabilities. This entire staff coordinates perfectly with each other for health support operations. Considerable military forces were directly committed in searching and clearing operations at the disaster a rea, almost right away after explosion. These committed forces were closely and directly supported by medical personnel for providing their first aid to the field. The military troops engaged on the cleaning operations’ area were provided with dust masks protection, handgrips for the protection of hands from hurts of metal scraping wastes, explosive shell pieces, etc. Hygiene and sanitation nods were also set up in support of all military forces committed on operations in field. Picture 5. The scene af ter the exp loded large caliber, shells scattered af ter the exp losion.

LESSONS LEARNED The bitter experience stemmed from this abovementioned huge explosion, has been subject of a careful consideration, in order to identify the problems, shortages and responsibilities. First of them was a re-assessment of the potential risks and threats that can face the military and civil community from the excess stock ammunition, but not only. Another problem that needed urgent solution was the training and early preparation of military forces, especially military medical personnel, for effective management of major human disasters. In this context, it has been discussed installing better utilization human and medical resources. In this framework, creating and establishing the necessary medical logistic reserve, especially on medicines and medical supplies at the depot and pharmacies network has been one of the most urgent General Staff’s decision. Effective and better coordination between domestic civil-military medical services capabilities with foreign assistance and support has been considered one of the main measure in order to speed up the process.

After Armed Forces medical Service intervention, it was the Forensic Medicine Institute that provided legal experts and necessary logistic stuff (plastic bags) for the for the removal of dead bodies and body wastes found and further on, for the transport of corpses.

Last, but not the least, the Health Directory in the General Staff has established or updated all the medical Standard Operation Procedures (SOP) for any similar situation in the future, in order these kinds of situations be effectively managed.

All dead animals and poultries found within and around the explosion area were disinfected with hypochlorite and buried in deeply grounded landfills. For this purpose Albanian Armed Forces veterinary staff was involved in identification of animal and poultries dead bodies, in coordination with specialized stuff and counterparts of country’s other veterinary agencies to prevent the spread out of infections and epidemics.

Based on the abovementioned lessons learned, all the difficulties and problems have been considered and solutions have been reviewed. Any plan, any program at any site related to the elimination of the excessive stockpiles of munitions have been vested with disciplined medical measures. Medical teams that were equipped with all the necessary techniques were present from the beginning to the end of the process. The teams that were in charge of the elimination process have been certified not only from the professional point of view but from the medical point of view as well in order to successfully face even the smallest health situation. At any case, the military hospital has been devoted a ready medical team on 24h b ases in order to respond in time to any unexpected situation.

All military forces and other personnel that participated in the operation applied prophylactic vaccination with a dose of Rappel with anti-tetanus Immunoglobulin 1ml for 600 persons. (Picture 6).

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An additional health problem was the dead animals and poultries. In the disaster area some 233 (19 cattle, 4 small livestock, 3 pigs, 4 equines and 203 birds) dead animals and poultries were found, disinfected and buried.

International Review of the Armed Forces Medical Services

Nowadays Albania has completed the excess munitions eliminating process, but very strict rules and instructions for the management readiness and reserve munitions

Revue Internationale des Services de Santé des Forces Armées

ABSTRACT

have been determined. Medical training is definitely an integrated part of professional training. This demilitarization process was accomplished using different methodologies, in order not to avoid any massive ammunition consolidation. The primary emphasis was placed on the industrial dismantling of munitions at three distant military factories: Mjekës, Gramsh and Poliçan. When industrial demilitarization was impossible due to technical and safety reasons, we carried out open detonations at 11 demolition ranges throughout the country, with all detonation sites approved by Parliament. A much smaller amount of munitions were sold and exported, generating much needed revenue to help fund the demilitarization effort. As part of the demilitarization process we have been able to close 23 legacy munitions storage locations. It has been decided an extremely rigorous process of site-cleaning, checking and certification prior to declaring any site free of munitions or explosive material. At any case rigorous standards has been decided related to oversight and certification role while in the supervision, training, accreditation and certification processes in order to ensure safe operations. At the end of the year 2016, more than 100.000 tons of munitions have been eliminated, which equates to approximately 450 million rounds of various calibers. Due to the above mentioned measures, not even the smallest accident occurred. All the process has been completed in a safe and secure environment.

CONCLUSIONS The transformation of the country’s defense concepts in this decade aimed at the ultimate eradication of the paranoid legacy of the past. One of the fields of the transformation was the elimination of old ammunition, explosives, weapons, large armaments and dangerous chemicals. They were not only an excessive burden, but also posed a threat to the security and safety of the population in the country and beyond. The volume of work, the duration and the risks associated with it were of a great experience.

Introduction: Albania, like all former communist countries, inherited from its 50 years a large arsenal of weapons and ammunition stockpiles, as shells and projectiles of various calibers, which seriously jeopardized the lives of people and communities throughout the regions of their deployment. After the 1990s, the Albanian Armed Forces embarked on the path of transformation and integration of Albania into NATO. In this framework, the implementation of defense reforms aimed to reduce and modernize the military. Methods and materials: This is a descriptive study of the experience gained by a major event occurring at a disestablished former military facility in Gërdec, on March 15, 2008, about 10km northwest of Tirana. The ammunition collected for demolition exploded, creating a huge detriment in the health of the populace and urged the immediate commitment and involvement of many disaster-related state agencies. Results: This disaster caused 26 deaths and over 300 injuries. More than 60% of the injured were treated in the Military Hospital. Support, material assistance and aid were also provided by allied countries. Discussion: From this event we learned that re-assessment of the potential risks and threats that can face the military and civil community, caused by an excess stock of ammunition, was needed. The training and early preparation of military forces, especially military medical personnel, is necessary to ensure an effective management of major human disasters. Establishing or updating the medical Standard Operation Procedures (SOP), for any similar situation in the future, is necessary in order to effectively manage these kinds of situations. Conclusions: Currently, Albania no longer has excessive or risky armaments and ammunition stockpiles, so its defense efforts and investments are now addressed in other fields of full integration into collective defense structures and procedures. The Albanian Armed Forces are provided with welldefined intervention plans in order to effectively prevent any future situations such as this.

In this process, the Military Hospital was more effectively positioned to adjust its experiences, structures and procedures to cope with emergencies, similar to those that may be caused by weapons and ammunitions and other types of emergencies.

REFERENCES 1. POWELL, Mike: "The New York Times - Breaking News, World News & Multimedia". International Herald Tribune. Retrieved 2017-01-08.

Support and material assistance and aid provided by allied countries in this case, as in other emergencies and wounded hospitalized in other countries served even more to the opening up of the country and its integration into the modern treatment of health services.

2. POWELL, Mike: "Death toll from Albanian dump blast climbs". Usatoday.com. 2008-03-21. Retrieved 2017-01-08. 3. KAKARRIQI E: “General background of Potential Disaster Risks in Albania”, 3rd Public Health Fund of the Institute of Public Health, Conference of Institute of Public Health, 11-13.2.2006 Tirana, Albania.

Today, the Albanian Armed Forces are provided with well-defined intervention plans in order to effectively prevent such situations.

4. Law No. 72/2015 "For the approval of the Military Strategy of the Republic of Albania", 2015, pg.33.

Currently, Albania no longer has excessive or risky armaments and ammunition stockpiles, so its defense efforts and investments are now addressed in other fields of full integration into collective defense structures and procedures.

International Review of the Armed Forces Medical Services

5. Pierre COBINET, Tom VAN BENEDEN, "Small Arms Survey The regional Approach to Stockpile Reduction", April 2012. 6. "Ushtria" - Albanian Defence Newspaper "NATO: The unique case of Albania for the munitions annihilation", October 2012.

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